The Hair Dr, Leeds Private Hospital

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 assessed 8 quality statements for this key question. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked to see if people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

This is the first inspection for this service. This key question has been rated Requires Improvement.

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 listened to concerns about safety and investigated and reported safety events. Lessons were not always learnt to continually identify and embed good practice.

Leaders told us they currently used a paper-based incident reporting system but were soon to move to an electronic version. Leaders said all staff were encouraged to report incidents and outcomes were shared for learning. We did not see any examples of staff involvement in investigating safety events, or being provided with the opportunity to make comments when they were informed of the outcomes at staff meetings.

As part of the interview process during the assessment we found leaders were unable to correctly describe the duty of candour regulation. They articulated it to mean following policies. We requested copies of any complaint response letters; however, none were provided, this meant we were not assured any complainants received an apology when things went wrong.

Leaders gave two recent examples of complaints regarding management of post-surgery expectations. Leaders said staff involved in the complaint were encouraged to complete reflective pieces to ensure issues were not repeated.

Leaders were able to provide many examples of compliments received, however the Staff Clinical Governance meeting agenda did not include any of this feedback to staff.

We were initially provided with the policies in place to support a learning culture however, some of these did not have an approval date, review date, owner identified and no version control. Following inspection we were provided with policies that had all pertinent information included.

The service stated it had a positive culture of safety and staff who worked in the service were supported to raise safety concerns. The service provided copies of staff clinical governance meetings minutes, which showed incidents and complaints were on the agenda, however these only included bullet points, with no record of discussion, and therefore, did not provide assurance these were effective.

Compliance was monitored using audits; however, the service did not provide examples of all audits which had taken place which meant not all opportunities for learning could be identified and the leader was unable to say when these audits were shared with staff.

People using the service said they felt safe whilst they were undergoing their procedure and they were well supported by the staff, not only whilst they were having their procedure, but as part of the before and after care.

Staff told us they knew how to report incidents and were provided with feedback.

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.

People told us the service provided them with adequate follow up appointments after their procedure. They said they received both written and verbal explanation as to what was to happen at every point in their treatment and who to contact if there was any queries or emergencies. At their procedure they said they had been supported throughout by a member of the team.

Staff told us they supported people whilst they were undergoing their procedure.

Leaders told us they ensured people had a comprehensive follow up schedule beginning the day after the procedure and lasted up to 1 year post hair transplantation, with flexibility to see them more often if needed.

The service had a deteriorating policy in place for anyone undergoing their procedure who needed to be transferred for emergency care.

The service provided day care procedures only, but did have a policy in place for anyone who needed to stay overnight, but we were given no examples of this being used.

We did not observe any examples of patient paperwork being left unattended or computers left unlocked.

The most recent audit of people's records showed 96% compliance with completion.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

People told us they felt safe whilst they were undergoing their procedure and they had not had to raise any concerns.

Staff had received training specific for their role on how to recognise and report abuse. Staff had completed safeguarding training for adults and children up to level 3 and 100% of the staff had completed level 3 for Adults and Children. The Safeguarding lead had completed safeguarding level 4 training.

All Disclosure Barring Service (DBS) checks were in place for staff.

The Safeguarding Lead was able to describe the process for informing the local authority of any safeguarding referrals and had made one referral in 12 months.

The service had a Safeguarding and CCTV policy in place which they used to safeguard people whilst undergoing their procedures, people were made aware of CCTV in pre-assessment.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people's needs that was safe, supportive and enabled people to do the things that mattered to them.

People said they were provided with a comprehensive explanation and patient information regarding what would happen in the surgery and aftercare. All risks were explained, and they were given the opportunity to ask any questions.

Staff completed risk assessments for each person at pre-assessment, using a recognised tool. This included checklists to identify potential risks such as allergies and assessing peoples' medical history and suitability for treatment.

Staff used a nationally recognised tool to identify people deteriorating and escalated them appropriately. The service had a deteriorating patient policy which defined clear roles and responsibilities for staff to act in an emergency.

Staff had completed resuscitation training to care for people in an emergency.

The service had implemented a World Health Organisation (WHO) "Five steps to safer surgery" policy and checklist audit. We were told that this was audited every month. Confirmation of this audit was provided following inspection.

The service said there was a Medical Advisory Committee which approved each surgeon's practice scope, reviewed Mortality and Morbidity, infections, complaints, and incidents. They said an open discussion was encouraged.

The Emergency Drugs Risk Assessment stated medication was checked weekly and oxygen and defibrillators checked daily, however when we checked the defibrillator maintenance record checklist we found it contained errors and omissions such as frequency of check, gaps in dates and signatures from staff completing the checks.

Staff told us stock rotation was in place to ensure the oldest stock was used first. However, we found multiple examples of single use equipment, which was out of date, which meant were not assured that oversight of stock was effective and could increase the risk of avoidable harm.

We found out of date testing equipment in the emergency cabinet.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

A process was in place for safety checks of specialist equipment. However, we found the emergency trolley was not locked and was in a corridor which could be accessed by any member of staff (both clinical and non-clinical) and any unsupervised patient or visitor.

The service had an operating theatre on the ground floor and hair procedure rooms were located on the floor above. The theatre was used for cosmetic surgery, where a sterile environment was required, and patients could require general anaesthetic. The placement of the area in the theatre where the surgeon prepares for sterile surgery was not in line with best practice HBN 26 Facilities for Surgical Procedures. We saw that the area for hand washing was not the required distance from the sterile field which could increase the risk of cross contamination and infection.

We found multiple items of contaminated equipment in the theatre which would prevent effective cleaning and could have increased the risk of infection. This was escalated immediately to the Registered Manager who removed this equipment from the area. During the factual accuracy process the service provided additional information regarding processes put in place to avoid a recurrence.

Within the procedure and aftercare rooms we found hand gel that had expired. We also found unlabelled spray bottles with no description of what they contained, there was also no date of preparation or expiry. This was a risk as there was no way of identifying the product or it’s safe use.

We saw examples of equipment used for patients being contaminated with blood which could increase the risk of cross contamination.

The cupboard where substances hazardous to health (COSHH) were stored was locked, however, we found out of date hand gel stored in it and the unsafe storage of both cleaning and non-cleaning products such as paint. During the factual accuracy process the service provided assurance that the paint and hand gel had been removed from the cupboard. The service described an audit undertaken of the COSHH procedure, we requested copies of completed COSHH audits, but none were provided, this meant we were not assured that these audits were undertaken. During the factual accuracy process the service provided evidence of learning that COSHH processes would be more effective in the future.

People said they were happy with the environment and found it clean and did not see any areas that were untidy. They saw staff wearing appropriate Personal Protective Equipment (PPE).

Leaders told us about a new centre which was being built which would include new theatres and beds so people could stay overnight if required.

All the hair transplant procedure rooms met the requirements for the procedures carried out in them.

All electrical medical equipment had been calibrated as per manufacturer guidance.

Fire, cleaning kitchen, slips, trips and falls, consent and health and safety risk assessment were all in date. Clinical waste was managed externally, with a policy in place which was audited annually.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people's individual needs.

People told us there was someone around to help them at all times and they always had a chaperone with them. They had not needed to wait for assistance.

The service had enough nursing and support staff to keep people safe. There were 18 full time staff with 2 staff vacancies.

On the day of inspection, there was one person undergoing a procedure on site, which we observed. The staff worked well together.

Staff told us they received training at induction and ongoing training appropriate and relevant to their role. Staff worked closely with the surgeon and were supervised during procedures. Staff shadowed and had supervised practice before they completed their training. Usually only 1 person a day was scheduled for a procedure which meant there was no time issues on having to get through training quickly.

The hair surgeon had an active GMC registration and had recently completed their annual professional revalidation.

Leaders could show they had a robust process for monitoring mandatory training among staff, including a quarterly audit. The January 2025 audit reported 100 percent of staff had completed Mandatory and Safeguarding Training that year.

Leaders regularly reviewed the registrations and revalidations of relevant clinic staff to make sure they were up to date. Leaders gave all new staff a full induction before they started work. New members went through a probationary period and completed competency training during contracted hours. Bank staff received a full induction.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading.

People told us they had not had any issues with infections following their procedures.

The service had an Infection Prevention and Control (IPC) Policy in place with monthly audits which were conducted by the Clinical Governance Team. The service provided copies of audits in all aspects on infection control including deep cleaning and daily environmental checks. Audits were discussed in Governance meetings.

However, we observed staff walking around the building and outside still wearing masks and theatre hats which should have been removed when leaving the clinical area. We observed PPE not being worn correctly in the decontamination room even though the poster on the wall advised what they were required to wear.

Staff had received Infection control training as part of mandatory training. All clinical staff were bare below the elbow. There was a good supply of hand cleanser within clinical areas, however, some of these were out of date and others were unclean at the exit point which did not provide assurance that hands were clean. This was escalated to the manager during the inspection; however, we did not observe immediate replacement of the hand cleansers whilst we were on-site. During the factual accuracy process the service provided evidence these had been replaced.

We were told that they reported infection rates at a national level, however owing to no reported infections in the past year this could not be evidenced.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff were always involved people in planning.

We observed that all drugs’ cupboards were locked, except for the emergency trolley which was in the corridor were all staff had access. We also saw a number of emergency medicines that were out of date.

All medicines in the theatre had been over labelled and in some cases the label was on top of the expiry dates which meant that medicines could be used that had expired. This could increase the risk of adverse reactions. During the factual accuracy process the service acknowledged the errors regarding label placement and provided evidence of learning to prevent a reoccurrence.

In a drugs fridge we found two syringes with a clear liquid inside and the label on the outside only provided the name of the drug with no dose, date, time, or initials recorded.

We found home remedy lotions, for example petroleum jelly, with no date opened on the containers. During the factual accuracy process the service acknowledged there were errors regarding the labelling of the topical agents, which were, albeit not high risk or out of date, nevertheless, were not labelled in accordance with best practice. The service provided evidence to show it had learned from the error and put in place steps to avoid a reoccurrence.

The service told us an audit, undertaken March 2025, showed high compliance with prescribing, administration, storage, and the controlled drug process.

People told us they were supplied with medication to take at home following their procedure. They said staff went through the medication to take home both before and after the procedure, which they found very helpful.

The service had a medicines management policy, which described the storage, prescribing and safe administration of medicines. Staff completed medicines records accurately and kept them up to date. We reviewed 6 medicine records and saw they were completed, signed, and dated. Staff recorded information about people’s allergies.

The service did not keep a stock of controlled drugs. Any controlled drugs required were provided on the day of the procedure from a local pharmacy and any unused ones collected at the end of the day.

Medical gasses were provided from a local company and stored in a locked, clearly identified cupboard.