My Hair Transplant

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 rated well-led as requires improvement.

We identified a regulatory breach in relation to governance and assurance processes in the key question for well-led, where we have told the service it needs to make improvements.

The service did not have clear governance, management and accountability arrangements. Although the service had a wide range of policies in place and these were accessible to staff, many contained inaccurate or inconsistent information. While audits were in place, they did not always cover the most critical areas in sufficient depth or scale to meaningfully support learning and service improvement.

However, staff felt respected, supported and valued. Leaders promoted a positive work culture based on equality, diversity and inclusion. Staff were supported to speak up or raise concerns.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff described a friendly and open culture centred on teamwork and delivering quality care. They spoke positively about the support received from managers.

Managers reported that progress against business objectives was reviewed during routine governance meetings and supported by a documented vision and strategy. The registered manager said the service was planning to expand to seven-day working.

Staff described a culture of learning and development, with opportunities for career progression from technician roles into senior and managerial positions. All staff had completed appraisals, which included discussions around development.

The registered manager demonstrated enthusiasm for the service and its future. The service’s vision and strategy document outlined broad aims based on core values and behaviours. However not all staff knew what the values and business objectives were.

Equality, diversity, and inclusion were promoted, and staff confirmed access to development opportunities. The training and compliance leads reported progressing from senior technician roles.

The registered manager reported that staff understood the context of the care they delivered and embodied the organisation’s culture and values. Staff described managers as visible, approachable, and supportive.

Leadership was structured with the surgeon and director as the overall lead, overseeing clinical managers and other surgeons. Managers were responsible for day-to-day operations and supervising technicians.

The service employed a diverse and inclusive workforce. Staff were encouraged to provide feedback through questionnaires and structured meetings, and progression was actively promoted. Staff we spoke with spoke positively about their relationships with managers and the surgeons.

The team participated in six-monthly team-building activities, and managers had recently implemented a salary increase in response to the cost of living.

Leaders had the skills and experience to manage the service. However, we identified shortfalls in governance and quality monitoring processes, which showed leaders did not always have effective management oversight or a clear understanding of key risks to the service.

The registered managers told us the service fostered a positive and open culture where staff felt comfortable raising concerns. Staff reported feeling confident that they could speak up and that managers would listen and respond appropriately.

Staff were aware of the whistleblowing policy and knew how to contact the Freedom to Speak Up Guardian if needed. The service had policies in place to support staff in raising concerns safely and confidentially.

The service had not received any whistleblowing concerns internally in the past 12 months. However, the Care Quality Commission had received one whistleblower concern during this period.

The service valued diversity in their workforce. Managers worked towards an inclusive and fair culture.

Staff told us managers engaged with them regularly and they felt confident their concerns were listed to. All the staff we spoke with told us they had not experienced any instances of unfair treatment, discrimination or harassment.

Managers told us equality, diversity and inclusion were embedded in the culture of the service. They told us staff recruitment processes enabled equal opportunities, and they engaged with staff routinely to maintain an inclusive work environment.

The service had an equality, diversity and inclusion policy and this was also incorporated in the recruitment policies and processes. There were support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns.

The service did not always operate effective governance processes. Although we saw some evidence the service discussed and implemented policies, audits, and opportunities to improve, these were not always effective or fit for purpose.

We found that some audit processes did not always promote good standards of practice. For example, despite staff having completed and checked cleaning audit forms, we found the areas checked were not visibly clean. We also found the medicines management audit form template included checks for controlled drugs and for medicines stored in fridges that did not reflect staff practice.

Similarly, we found that the service’s pain audit was insufficient in terms of number of cases reviewed, and effectiveness in identifying adequacy of pain management or learning for improvements.

Whilst the service had a range of policies in place, many contained inaccurate or inconsistent information. For example; the service’s treatment policy stated that mandatory training for clinical staff was required annually, when in practice it was completed every 3 years. The service’s monitoring policy referenced vital signs being monitored every 30–60 minutes during procedures, but both staff accounts and other documents indicated vital signs were only recorded before and after surgery unless complications arose. The safeguarding policy stated all staff should be trained to level 3; however, the training matrix showed technicians were only trained to level 2.

We also found that the blood spillage policy referenced the use of sodium hypochlorite or dichloroisocyanurate granules, but staff reported using standard disinfectant wipes. The freedom to speak up (FTSU) policy was incomplete, with bracketed placeholders for the company name not filled in. The risk assessment policy included incorrect details about staff groups, recruitment practices, and the layout of the clinic.

We also found further inaccurate or inconsistent information within the recruitment, infection control, and practising privileges policies.

We found the personnel files for directors were not sufficient to evidence the service had effectively checked the suitability of directors for their roles. However, some of the required documents were added to the files after our inspection.

Although we saw some evidence the service had acted on people’s feedback, the feedback survey response rate was low and we found there were missed opportunities to collect people’s’ feedback during their aftercare.

Managers told us they shared information and learning with external partners and demonstrated a commitment to collaborative improvement.

Clinic managers and the surgeon maintained regular communication with the external hair loss referral agencies. They shared people’s feedback and clinical learning to support ongoing development of the referral and assessment process. This partnership aimed to ensure that people received consistent information and a streamlined experience from consultation through to post-operative care.

Managers told us the service focused on continuous learning, innovation and improvement. They told us routine audits took place to monitor compliance, and learning was shared through daily huddles and routine meetings.

We saw minutes of meetings held with all staff, managers, and external surgeons which demonstrated an effort to improve practice, share knowledge, and support continuous learning across the service. These meetings included discussions on clinical performance, audit outcomes, policy updates, and shared learning from people’s feedback and incidents.

All staff underwent competency assessments every 6 months. These assessments included a variety of formats such as practical demonstrations, quizzes, and scenario-based evaluations. However, we noted that different competencies were assessed at each review. While this approach allowed for flexibility and coverage of a wide range of skills over time, it meant there was no clear oversight of how frequently each specific competency, such as administering local anaesthesia or infection prevention control, was reassessed. This made it difficult to ensure that all essential competencies were being reviewed consistently and regularly for every staff member.

The service had recently introduced an in-person people’s education workshop as a new initiative to enhance engagement with people who used the service. The aim of this workshop was to improve people’s understanding of what to expect before, during, and after their hair transplant procedure, including realistic outcomes and post-operative care requirements.

Managers told us the workshop was being trialled and would be evaluated based on people’s feedback and engagement. In addition to the workshop, the service was exploring other engagement methods, such as webinars, structured follow-up calls and enhanced content on the online portal.

These developments reflected a proactive approach to improving people’s experience and showed a willingness to collaborate, adapt, and learn for service improvement.