Renew Skin & Health Clinic Limited Ltd

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

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

This key question has been rated requires improvement. This meant there were shortfalls in the delivery of safe care and treatment.

The service was in breach of legal regulation in relation to fit and proper persons employed. This was because recruitment processes did not consistently ensure staff had the right skills, qualifications, and experience to keep patients safe.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always report or investigate safety events.

There was a process for recording incidents. Although we saw a medicines incident had been discussed at a staff meeting but it had not been reported and recorded in the incident log. However, the incidents that had been reported contained updates so we could see what processes had been put in place to investigate the incident, and actions taken to mitigate the likelihood of the incident occurring again, including sharing learning. For example, we looked at an incident regarding a patient who had been burned during a laser procedure. Staff had an initial debrief to look for learning. The registered manager carried out an investigation using root cause analysis methodology to understand what went wrong and shared the findings with staff to prevent similar incidents from happening again. They also arranged for staff to receive additional laser training. The registered manager arranged and paid for treatment for the burn to be carried out by a different service convenient to the patient. The patient received an apology and explanation of what went wrong.

The service worked with people 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 people moved between different services.

Patients received a consultation prior to any treatment taking place. At this appointment patients had an assessment of their suitability for treatment. This included taking details of their medicines, their medical history, and their psychological history. They were also asked about their allergies. Patients were then advised of the positive and negative consequences of undergoing a procedure and given time to decide if they wanted to have treatment.

Patients were asked to give their consent to information sharing with their GP. This was so important information could be shared. For example, to share information about a treatment outcome, or to flag significant issues that may have emerged as part of the assessment.

When necessary, the doctor wrote to the GP to share information about prescribing, surgery, or about the advice given following a patient's assessment or procedure.

The service worked with people to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

All staff received training to level 3 in safeguarding children and level 3 in safeguarding adults. Staff knew how to identify adults at risk of, or suffering, significant harm and what to do it they had a safeguarding concern. No safeguarding referrals had been made in the 12 months before our assessment.

The safeguarding policies contained information about local safeguarding teams. We saw safeguarding flow charts in treatment rooms so staff had easy access to information about what to do if they had a safeguarding concern.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, the service did not use a nationally recognised tool that could improve safety.

We saw evidence in patient’s records that they had been given information about the risk involved in their procedure, including about pain, infection risk, bruising, and bleeding. Patients were given verbal and written information about aftercare. All patients undergoing a surgical procedure were given the lead doctor’s contact details. They could contact them up until 10pm for support or advice following their procedure. After 10pm patients were advised to ring the NHS111 service for support.

We reviewed 8 treatment records for adult patients undergoing a range of procedures including hair transplants and found their physical health was monitored before, during and after treatment. Physical health checks included monitoring blood pressure and heart rate. Anxiety levels were recorded prior to treatment, and we were told a procedure would not occur if a patient’s blood pressure or anxiety levels were too high.

The World Health Organization (WHO) surgical safety checklist, or a modified version of this checklist, was not being used by the provider. The WHO checklist ensures that critical steps are carried for every surgery to protect patients from serious and unavoidable surgical complications. However, we reviewed the care pathways for patients and saw they contained preoperative safety checks. For example, to check if the patient had been given a clear explanation of what was going to happen next, if they had signed the consent form, and if they had any communication problems. We also saw patients wore a red band if they had an allergy, including an allergy to latex. This was to ensure extra checks were carried out if a patient with an allergy deteriorated and alternative treatments were required, or in case the patient needed treatment from the emergency services.

All staff had been trained in adult basic life support to enable them to recognise cardiac arrest, call for help, and start resuscitation. Emergency medicines were available if needed, including oxygen and adrenaline for anaphylaxis. The defibrillator was checked weekly to ensure it was ready for use.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The clinic was split over 2 floors. On the ground floor there was a consultancy room that could also be used to provide laser treatments for patients, there was ramp access for wheelchair users to this room. There was a disabled toilet, a waiting area, office, and store rooms. The first floor could only be accessed by a steep set of stairs which meant it was not suitable for wheelchair users. The first floor contained a theatre, a recovery room, a consultancy room, 2 rooms used for laser therapy, and a utility room for decontamination and storage of equipment. Rooms used for laser therapy had `laser in use' signs outside the door that were lit when the laser was being used.

We checked the stock of consumables used by the provider and found everything was in date.

We saw evidence equipment was regularly serviced, all of the equipment in use had an up-to-date service record. Records showed electrical equipment testing had been completed on the portable electrical equipment.

The service had suitable facilities to meet the needs of patients' families. The waiting room had enough seats for family members to accompany patients.

Staff disposed of clinical waste safely. Clinical waste bins were clearly identified and emptied regularly. Sharps bins were labelled and stored safely.

The service did not consistently make sure staff employed under practicing privileges and hair transplant technicians were qualified, skilled and safe to work with patients. However, substantively employed staff were qualified, skilled and safe to work with patients. They received support, supervision and development opportunities. Staff worked together well to provide safe care that met people's individual needs.

The provider did not have a process to ensure doctors who worked at the clinic under practicing privileges consistently provided the evidence required to give them a right to practice at the clinic. We looked at files for 5 doctors. Two doctors had not completed their application form to practice at the clinic which meant there was no information that would have allowed pre-employment checks, including disclosure and barring service (DBS) checks, to be carried out. Three doctors had not submitted evidence of renewal of their indemnity cover. One doctor was no longer working at the clinic but there was nothing to record why not. All independent healthcare providers who grant practicing privileges to medical practitioners must ensure they have a process to undertake necessary pre-employment checks to guarantee safe care and treatment is provided to patients at all times. When we returned to the clinic for our second visit, we saw a process had been introduced to ensure all of the necessary paperwork required to demonstrate the doctors working under practicing privileges were safe to do so.

The provider did not ensure all healthcare staff who worked at the clinic had the qualifications, knowledge, and experience necessary to provide safe care and treatment. We saw 2 different hair transplant technicians had been used to support 2 hair transplant procedures in the 12 months before the assessment. Neither of these technicians were substantively employed by the provider and neither had been subject to employment checks.

Because the provider had not got evidence to show pre-employment checks to ensure all staff working at the clinic were qualified and safe to do so, the service was in breach of the legal regulation relating to fit and proper persons employed.

However, there were clear recruitment processes for staff employed substantively by the provider. Records showed all necessary pre-employment recruitment checks had been performed, including taking up references and DBS checks.

Mandatory training was comprehensive and met the needs of patients and staff. We saw staff compliance with training was 100%.

Staff told us they received regular support, supervision, and development opportunities to enable them to do their job. However, they described supervision as something that happened on an unplanned basis rather than a structured meeting that was planned in advance.

The provider had previously used an outsourced human resource team to perform staff appraisals. The provider was in the process of developing a new system for staff appraisals. At the time of our assessment only 1 of the 4 members of the team had completed their appraisal under the new system. However, there was a short-term plan for the other members of the team to have their appraisal.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading.

Patients told us they thought the clinic was clean, and staff wore medical uniforms and used disposable gloves, aprons, and masks while carrying out treatments.

All areas, including those at height, were visibly clean and had suitable furnishings which were clean and well-maintained.

The service had a cleaner attend 2 days a week. We saw the cleaning schedule covered all areas of the clinic and had been completed twice each week. Staff were responsible for keeping the premises clean at all other times. We saw packets of disinfection wipes in all rooms so staff could perform cleaning in between patients.

Mops and buckets were colour coded to prevent cross contamination. Cleaning supplies were stored securely in a locked cupboard.

Staff followed infection control principles including the use of personal protective equipment (PPE). We observed staff wearing PPE to safeguard patients and themselves from possible cross infection. We observed staff using the correct handwashing technique.

Decontamination of surgical equipment was undertaken by staff using an autoclave or ultrasonic cleaner. An autoclave uses pressurised steam to kill harmful bacteria, viruses, and fungi. An ultrasonic cleaner used high-frequency sound waves transmitted through liquid to scrub items clean. Staff used a tracking system to ensure surgical equipment was properly sterilised and within its safe usage period by tracking expiration dates. If equipment went out of date while in storage the system flagged it for removal.

Antibiotics were prescribed to patients when this was considered best practice. For example, when undergoing minor surgical procedures where bacterial infections were likely.

Infection prevention and control audits included audits of the environment, handwashing, and decontamination processes. The environmental audits performed between July 2024 and the end of January 2025 showed a 99.3% compliance rate. Other audits undertaken during the same time period, including audits for hand washing, use of PPE, handling and disposal of sharps, cleaning equipment, and waste disposal, showed 100% compliance.

The service did not always make sure medicines were safe and met people’s needs.

There was no process to ensure national medicine alerts or recalls were acted upon to ensure the provider took action where needed to protect patients from harm.

The provider had a medicines management policy but it did not reflect the current arrangements for the management of medicines, or auditing the safe and secure handling of medicines. Medicines were stored securely and all the medicines seen were within date. However, medicines were not always managed safely. There was no separation of topical and oral medicines, and there was no temperature monitoring within the medicine storeroom to ensure the safe storage of medicines. The service did not undertake any medicines audits for the safe and secure handling of medicines or to ensure prescribing was in line with best practice guidelines for safe prescribing.

On our second visit to the clinic we saw an improvement to the storage of medicines. Internal and external medicines were stored separately and a system for monitoring the temperature of the medicine storeroom had been introduced.

Medicines requiring storage in a refrigerator were stored safely. The temperature of the fridge was monitored to ensure the integrity of the medicines stored there.

Emergency medicines were available. Checks were undertaken to ensure the medicines were within date and safe to use in an emergency. This included oxygen and adrenaline for anaphylaxis. Appropriate warning signs for oxygen were visible on the treatment room door.

Staff prescribed and administered medicines to patients in line with legal requirements. They recorded the batch numbers and expiry dates of medicines that had been administered. Although we did review 1 patient record that did not contain a recorded of the medicines administered during treatment. Maintaining records of medicines administered ensures, in the event of a medicine incident, the provider would be able to refer to the medicines administered so action could be taken if required.

There was a system to ensure patients medicines and past medical history were recorded prior to any treatment. Allergies were clearly documented in all the patient records we looked at.

The clinic used some medicines ‘off-label’ which means the medicine had a licence for treating some conditions however the prescriber prescribed the medicine to use it in a different way than stated in the licence. The provider ensured patients were aware of this before they consented to treatment and patients signed a consent form in agreement.

Physical health monitoring checks were undertaken prior to prescribing and administering medicines to patients.

Post operative prophylaxis treatment such as antibiotics were prescribed for some procedures.