My Hair Transplant

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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 rated safe as requires improvement.

We identified regulatory breaches relating to infection, prevention and control processes, involving people to manage risks and medicines optimisation in the key questions for safe where we have told the service it needs to make improvements.

We found the service did not have effective systems to keep the premises and equipment clean and well maintained.

We found the service did not have full oversight and management of people’s pain during the initial administration of local anaesthesia.

Medicines policies and staff knowledge were unclear, particularly regarding controlled drugs and the administration of local anaesthetic by technicians. Medicines audit records also included checks completed by staff that did not reflect staff practice.

Not all staff were able to describe what safeguarding was despite having completed the safeguarding training. None of the surgeons were on the specialist register.

However, we also found areas of good practice. The service had enough staff to care for people and keep them safe. The service managed incidents well and had a culture of learning.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us the service had a positive culture based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt and good practice was embedded.

People who used the service told us that they understood how to raise concerns with staff.

Staff knew what incidents to report and how to report these. Managers investigated incidents appropriately and remedial actions were put in place for learning and improvement. Staff told us they discussed incidents in the daily huddles and during the monthly staff meetings. The service did not report any serious incidents in the 12 months prior to our inspection.

We saw evidence of learning from incidents and actions put in place to reduce recurrence.

People who used the service told us they attended an initial consultation to assess their needs and preferences and to determine their eligibility for surgery. However, they usually had this consultation not with the service itself, but with an external hair loss referral agency.

Clinic managers told us that most people who used their service completed their initial consultation with a hair loss referral agency that specialised in referring people to surgeons for hair transplants. However, staff working for the referral agency were not medically trained.

People told us that staff monitored them during their procedure and provided information about post-operative recovery and the aftercare service as part of the discharge process. People received access to an online portal tool the service developed, which included videos, photographs, and information related to their hair transplant.

Staff told us they used an electronic booking system to manage people's appointments and post-operative follow-up appointments. Staff understood the process for managing people's risks during an emergency. They told us they carried out routine observations during surgery and stabilised people with deteriorating health before contacting emergency services.

We spoke with one of the hair loss referral agencies. They told us they captured all relevant information during the initial assessment. If there were any medical concerns, they consulted directly with the surgeon and booked an appointment for further review. They accessed the service's calendar and scheduled the date for the people to attend their hair transplant. They booked this 14 days in advance to give people enough time to decide whether to proceed with the procedure.

Managers told us that once they confirmed the surgery date, the service sent people information including access to the online portal, a health questionnaire, and a consent form to review before attending surgery.

The service's inclusion criteria excluded certain people from treatment, such as those with complex health conditions or those physically unable to lie face down for prolonged periods.

The health questionnaire was completed by the hair loss referral agency and again by a clinic manager 1-2 weeks prior to surgery. The surgeon reviewed the completed health questionnaire on the day of the procedure.

Managers told us they liaised with people's general practitioners (GPs), with consent, if they had any queries about the person's health status or required test results prior to surgery. We saw evidence of GP information-sharing requests the service made before agreeing to surgery.

However, although some individuals had their hair transplant procedures rescheduled due to the need for additional medical tests or GP follow-ups, some of these postponements might have been avoided if a surgical assessment had taken place before the day of the procedure.

Staff undertook care record audits every six months, which showed good levels of compliance. We reviewed 10 care records, all of which were complete and up to date.

The service had a discharge policy. Staff stored discharge summaries electronically in the in-house booking system. We observed samples of discharge summaries, which were completed adequately.

Staff said they understood the provider's safeguarding policy and reported that they completed mandatory safeguarding training for both adults and children. A review of training records confirmed 100% compliance with level 2 safeguarding training for both adult and child safeguarding.

Despite this, staff gave mixed responses when we asked about their understanding of safeguarding and the identity of the safeguarding lead. Staff said they reported concerns to the managers, who then made referrals if required. The service had not recorded any safeguarding concerns or made any referrals at the time of our inspection.

The registered manager completed level 4 safeguarding training, while clinic managers received level 3 training for both adults and children. Other staff members, including senior staff, extractors, and junior technicians, completed level 2 training. However, the safeguarding policy stated that all staff should be trained to level 3 and had not been updated to reflect the details of the safeguarding lead.

Inspectors observed safeguarding posters displayed in treatment rooms, which included local authority contact details for managers to use if needed.

People who used the service told us that staff assessed risks related to their procedure and discussed these with them before they underwent surgery. People also told us that staff carried out routine observations before and after their procedure.

Staff knew how to identify and manage risks. They told us they assessed risks during the initial consultation (usually conducted by an external service) and again on the day of surgery to determine whether people were suitable for the procedure. Care records showed that staff completed health questionnaires for each person upon admission to the clinic, which included information about physical and mental health problems. However, there was a risk of surgery being cancelled on the day, as this was often the first time individuals were assessed by the surgeon prior to surgery.

We reviewed care records where staff identified changes in people's physical or mental health needs, which led to surgery being rescheduled until further information and management plans were put in place.

Staff explained how they monitored individuals' care and treatment, including conducting vital observations. They recorded blood pressure and pulse rate before and after surgery, unless they identified specific concerns. This practice did not align to the service's monitoring policy which required people's vital signs to be monitored every 30—60 minutes.

Staff completed a checklist and provided verbal post-operative instructions. They also showed people how to access the online portal. Staff scheduled post-operative follow-ups at 2 days, 7 days, and 14 days, with additional reviews at 6 months and 12 months.

People who used the service had access to the surgeon and clinic managers via a smartphone messaging application, which enabled weekday communication for any concerns. The service also responded to telephone calls and app messages for additional advice. We observed prompt responses to people through the app and witnessed staff providing telephone advice to a person who called with further questions.

Several people who used the service reported experiencing significant pain during the administration of local anaesthetic and said they felt unprepared for it. The surgeon's explanation for this was that initial discomfort resulted from the acidic nature of the local anaesthetic solution, which caused pain until nerve endings were blocked.

Managers told us staff monitored pain and discomfort during surgery and offered additional analgesia when needed. Care records showed the use of pain score tools and appropriate pain relief prescribing. However, the service's pain audit did not include the initial administration of local anaesthetic, meaning staff did not routinely monitor pain at that stage.

The service conducted six-monthly pain audits, reviewing five randomly selected cases to assess pain during the extraction, channel creation, and implantation stages of the surgery. While records showed minimal pain levels and full documentation, the sample size represented only around 1% of people who had undergone procedures and excluded the anaesthesia stage, which limited insight into early pain experiences.

The service did not consistently identify and manage potential risks within the care environment. Staff did not always ensure that equipment supported the safe delivery of care. For example, several clinical waste bins in the operating rooms were broken, and some support cushions were visibly soiled, posing a risk of cross-contamination. Following the assessment, the provider took prompt action to address these concerns, replacing the bins and disposing of the affected cushions.

Staff told us there was a clear process in place for reporting equipment faults. However, they also noted delays in the repair or replacement of some items. For instance, there had been a delay in replacing damaged and stained headrests used on the operating couches.

We saw internal CCTV cameras in some of the treatment rooms. The registered manager told us that these were legacy cameras and none are now in use.

Despite these issues, people who used the service told us the environment was clean and tidy and reported no concerns related to equipment.

Staff similarly reported that the premises and equipment were appropriate for delivering safe care. They stated that there was sufficient access to equipment and consumables as needed. There was no evidence that managers had taken remedial action to address the issue of broken clinical waste bins. However, following our assessment prompt action was taken to address this.

Staff confirmed that routine monthly stock checks were carried out to ensure adequate supplies and to verify that consumables and single-use sterile items were within expiry dates. We observed that stock, oxygen supplies, and personal protective equipment (PPE) were in date. A monthly safety check of resuscitation equipment was also carried out.

The service was accessible via 2 lifts. Staff stated that in the event of an emergency or lift failure, an evacuation chair was available for use if required.

The registered manager held responsibility for the maintenance and servicing of the premises, including contracts related to the general environment. Electronic logs were maintained to record equipment checks and repairs.

Managers reported that there were sufficient qualified, skilled, and experienced staff in place, supported through effective supervision and development. A recent recruitment drive had resulted in the appointment of several new staff members.

People who used the service told us there were enough staff in the clinic. Most people were happy with the way staff communicated and interacted with them

Staff told us there were enough staff to provide safe care and treatment. They told us their workload was manageable, and they received good support from managers.

Staff told us they kept up to date with mandatory training and were supported to complete this. Manages told us they monitored training compliance and informed staff when they needed to update their training. Staff and managers had access to the training portal where they monitored training progress.

We reviewed staff training logs and found that all staff had completed mandatory training. However, several had done so after our on-site inspection. For example, dementia awareness training was completed by multiple staff members following our visit.

Managers reported that staff completed an induction and competency-based training when starting their roles. Competency assessments were carried out every 6 months using various formats, including practical demonstrations, multiple-choice quizzes, live scenarios, and written tests. Managers told us the themes for competency assessments varied every 6 month.

Staff told us they received annual appraisals and we saw that 100% of eligible staff had completed this.

Staff were positive about on the job learning and development opportunities and they had access to online training with videos of the surgeons demonstrating procedures.

The service had 2 employed surgeons and one locum surgeon. All the surgeons were registered with the General Medical Council (GMC) and registrations were up to date with no outstanding queries or revalidation issues. None of the surgeons were on the specialist register. The surgeons did not work in the NHS but were experienced and had undertaken significant numbers of hair transplant procedures. They told us their performance was routinely monitored through appraisals and no significant concerns had been identified through their most recent clinical appraisals.

We saw the service had enough staff to keep people safe. Sickness levels were low and staff turnover was 18% for the past 12 months. The service recruited 16 new staff in the past 12 months and 4 staff left the service. Senior technicians, extractors and junior technicians supported the surgeons.

We observed staff interacting with people and saw staff were friendly, calm and polite when communicating with people and delivering care and treatment.

The reception area had several posters `spotlighting' hair transplant clinicians some who did not work for the service which could lead people to believe that they worked at the clinic.

The service did not consistently assess or manage infection control risks. Staff did not always detect or mitigate the risk of infection spreading.

We observed 9 treatment rooms, the decontamination room, reception, and toilet facilities for staff and people who used the service. Whilst these areas appeared visibly clean, we saw several rooms were worn, with scuffed walls, loose grit and paper on the floor, and signs of superficial rather than thorough cleaning. We saw dust was present on high surfaces and fire extinguishers, and 2 hand gel dispensers were not working.

One treatment room had only a single sink, posing a cross-contamination risk due to the lack of separate facilities for handwashing and cleaning instruments. The service ceased using this room for surgery following the inspection.

Although daily cleaning schedules were in place and checked by senior staff and clinical managers, these did not identify issues observed during inspection. These included soiled or taped headrests, stained blinds, chipped flooring, damaged worktops, and soiled support bolsters and under-sink areas. The service took immediate action to address these concerns.

Staff were trained in hand hygiene, but audits had not been conducted to verify compliance. Following the inspection, spot-check audits were introduced.

Staff were trained in hand hygiene, but unannounced audits had not been conducted to verify compliance. Following the inspection, spot-checks audits were introduced

Staff used disinfectant wipes for cleaning equipment and floors and reported using them for blood spillages. However, this did not align with the service’s policy, which required blood spills to be managed with disposable towels and treated with appropriate disinfectants such as sodium hypochlorite or dichloroisocyanurate granules.

Despite the issues noted, people reported that the premises and equipment appeared clean and tidy. We observed appropriate use of personal protective equipment (PPE), hand hygiene, and correct handling of clinical waste, including labelled sharps bins and external waste contracts.

Staff had completed mandatory infection prevention and control (IPC) training and could access IPC policies electronically.

The service benchtop sterilisers for sterilising instruments. Benchtop sterilisers are not compliant with the Department of Health Technical Memorandum 01-01: management of surgical instruments (medical devices). The guidance recommends that desktop sterilisers should only be used as a last resort. If used, there ‘should be measures in place to audit each use of the steriliser and identify which cycles are for the steriliser’s routine validation and which are for surgical decontamination’. This audit should ensure that the steriliser is only used for instrument decontamination in exceptional circumstances.

Sterilisation was carried out by trained technicians, with appropriate clean-to-dirty flow in the decontamination room. Instruments were sterilised daily, even if unused. Service records for the benchtop sterilisers were up to date, and cycles included indicator strip testing in line with Department of Health guidance. However, the service did not carry out additional testing such as protein or helix testing to verify sterilisation efficacy.

Staff stored medicines in their original packaging in lockable cupboards which clearly labelled the type of medicine. The service had standardised stock lists of medicines used for procedures and for people to take home. The service used local anaesthetic medicines, as well as adrenaline, analgesics and antibiotics. Medicine stocks were checked daily by designated staff and all medicines were prescribed by the surgeon. We observed 10 treatment records, which documented the medicines used including batch numbers and expiry dates.

All medicines had storage requirements below 25°C. We observed room temperature logs for April-June 2025 which showed medicines had been stored below 25°C. The clinic manager told us they had an air conditioning unit in case the room temperature raised to 25°C or above.

The service reported one incident relating to medicines management. This related to staff not locking a vial of lignocaine in the correct cupboard which did not result in any harm and immediate learning took place.

The service had emergency medicines available to support the management of any unexpected clinical incidents. These were in date and audited. We saw from the June 2025 medicines audit that the midazolam had expired and required replacement.

The clinic manager reported that the service did not hold any controlled drugs (CDs). However, the June 2025 medicines management audit record showed evidence of CDs being stored, checked, and balanced securely. This indicated the clinic manager was not aware that controlled drugs were held on site.

The medicines management audit record also included a check that had been completed by staff for medicines fridge daily temperature records being maintained and within range (2-8°C). However, during our inspection staff reported they did not have any medicines that required storage in fridges with temperatures between Daily temperature records maintained and within range (2-8°C). This showed the medicines management audit form did not reflect staff practice.

At a previous inspection of the service, we noted that hair technicians told inspectors they administered local anaesthetic injections however this practice was not detailed within the service's medicines policy and staff were unable to explain the training they received. During this assessment, we found that this practice had continued, and that the medicines policy still did not reflect the roles, responsibilities and competencies required for administering local anaesthetic.

The lead surgeon told us some hair technicians had been trained to administer subcutaneous injections. Risks were mitigated by ensuring technicians always worked under the supervision of the surgeon carrying out the hair transplant procedure and that they had undergone training to administer subcutaneous injections. We looked at records for 7 technicians, which showed they had undergone training and competency-based assessments for administering subcutaneous injections during 2022/23 and these competencies had all been updated during June 2025

The surgeon told us there had been 3 instances in the past 12 months where they prescribed a low dose pre-med sedative for people with anxiety to help them relax before undergoing hair transplant surgery. Where this was agreed, the surgeon told us people were assessed for suitability prior to undergoing procedures and allowed additional time for recovery before being discharged. The sedative was prescribed by the consulting surgeon for a person to collect from a local pharmacy and bring to the clinic on the day of their procedure.

The prescription and care records for all 3 people who had been prescribed sedatives showed They had been assessed by the surgeon prior commencing procedures and the sedative was administered in the presence of the surgeon and documented in each care record.