DrDucu London

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 rated Safe as requires improvement because the service did not always manage medicines safely or demonstrate effective oversight of medicines optimisation. We found shortfalls in medicines storage, administration records, audit reliability, staff knowledge and antimicrobial stewardship. These issues meant leaders could not be assured that medicines were consistently managed in line with policy, legal requirements or best practice.

However, we found positive practice in other areas of safe care. The service had systems for reporting and reviewing incidents, and staff told us they could raise concerns. The environment and equipment were generally clean and maintained, and managers ensured staff received training to support safe care and treatment.

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 had systems and processes for staff to report incidents including near misses and for these to be acted upon. Managers had oversight of all reported incidents to identify themes and trends. There were service specific policies and processes for staff to follow when reporting incidents however some of the policies did not have a review date. Clinical staff we spoke with were able to explain how to report, categorise, and investigate incidents.

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. All staff we spoke with knew what incidents to report and how to report them and did so in line with the provider’s policy. Staff told us they received feedback from incidents they reported, and learning from incidents was shared in meetings and by email, minutes of meetings reviewed confirmed this was the case. Leaders told us they currently used a paper‑based incident reporting system but were soon to move to an electronic version, however no date was given for these changes.

We were told performance outcomes were 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.

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 that staff monitored them during their procedure and provided them with 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 if the patient deteriorated, they would stabilise the patient before contacting emergency services. The service had a deteriorating policy in place for anyone undergoing their procedure who needed to be transferred for emergency care.

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

Patients were asked to give their consent to information sharing with their GP so that important information could be shared with their GP. 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. All staff received training to level two training in safeguarding children and adults. Staff knew how to identify adults at risk of, or suffering, significant harm and what to do if they had a safeguarding concern.

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.

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 one hundred percent compliance with level three safeguarding training for both adult and child safeguarding. The CQC registered manager was the safeguarding lead for the clinic and had completed level three safeguarding training.

Despite completing training 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.

People who used the service told us that staff assessed risks related to their procedure and discussed these with them before they had their procedure at the clinic. 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 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.

Staff explained how they monitored individuals’ care and treatment, including conducting vital observations such as blood pressure, respiration, heart rate (pulse) and temperature before and after the procedure. We saw evidence that doctors carried out all necessary risk assessments for patients pre‑procedure. This included deep venous thrombosis (DVT) risk assessments, risks related to allergies, whether the patient was a smoker, had a medical history of heart attacks, strokes, diabetes etc, and an assessment of family history of venous conditions.

Staff completed a checklist and provided verbal and written post‑operative instructions. Staff scheduled post‑operative follow‑ups at one month, three months, with additional reviews at six months and twelve months.

All safety checks were reviewed and confirmed verbally by the clinical team during the pre‑procedure safety briefing. These were signed and dated by the clinical staff. Safety checks included written confirmation the patient’s health records were reviewed, their allergy history was reviewed, their medication information was updated, and the type of procedure confirmed and documented.

We noted that staff completed the World Health Organisation (WHO) five steps to safer surgery checklists for all theatre cases. The service also carried out audits for the WHO safer surgery checklists, of which one hundred percent compliance rates were achieved.

The service gave all patients information leaflets advising them what to do in the event of post‑procedure complications. This included informing patients of relevant contact details of the clinic and an out‑of‑hours telephone service for patients who required urgent advice and support. Patients were encouraged to follow this advice during courtesy follow‑up calls from staff, which were conducted after every procedure.

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 sharps bins were not labelled and dated, cleaning schedules in the bathroom were not completed consistently, mop buckets and mops were kept outside of the basement room posing potential risk of cross‑contamination.

We saw evidence of electrical wires and extension leads run along floors causing a trip hazard. This was escalated and the provider took immediate action to resolve it. Annual Portable Appliance Testing (PAT) had been undertaken in October 2025; however, we saw one extension lead in use that had not been tested within the last twelve months.

During our inspection, we saw the step into one consultation room was a trip hazard and was not marked with hazard tape. This could cause patients and staff to trip and fall, thus injuring themselves.

Staff confirmed that routine monthly stock checks were carried out to ensure adequate supplies of consumables and to verify that consumables and single‑use sterile items were within expiry dates. We observed that medical items, oxygen supplies, and personal protective equipment were in date. A daily and monthly safety check of resuscitation equipment was also carried out. Staff stated that there was sufficient access to equipment and consumables to provide safe service.

The service’s upper floor was accessible via a lift. Staff stated that in the event of an emergency or lift failure, there was an evacuation chair to use if required. There was clear responsibility for the maintenance and servicing of equipment and premises, including contracts related to the general environment, with the registered manager undertaking this role. Electronic logs were maintained to record equipment checks and repairs and this was up to date.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patients’ individual needs.

The service had enough clinical staff including surgeons, nurses and hair transplant technicians with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff were made aware of their shifts in advance and could make requests.

The service carried out full pre‑employment checks including references, checks and professional registrations and qualifications before engaging staff. The service also carried out Disclosure and Barring Service checks for staff every three years, all the staff were transferred from the provider’s previously registered location to the newly registered location. The service had a stable workforce, as many staff members had worked at the service for over five years. Staff we spoke to said they felt the service was safe. They were able to take breaks during their shifts. New staff received a full induction tailored to their role before they started work.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, legionella awareness and sharps in care awareness training.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

The service did not always assess or manage the risk of infection. Infection prevention and control arrangements were not robust, with no comprehensive cleaning schedules or records in place.

Cleaning equipment was not correctly stored, and we observed mops and cloths kept outside and exposed to dirt. There was a lockable cupboard for hazardous cleaning substances; however, the keys were left in the door and could be accessed by unauthorised staff, posing a safety risk. This was escalated to the manager who locked and removed the key for safe keeping.

A storeroom used to store non‑hazardous materials was seen to be in a disorderly state, with hazardous materials also stored without appropriate separation, labelling, or security.

Although we observed that the environment was visibly clean and well maintained with cleaning schedules displayed in each area and cleaning checklists in the toilets, there was no evidence that these were completed and reviewed by the clinic management. The checklists had not been completed since March 2026. We spoke with a member of cleaning staff who informed us they followed cleaning schedules of the clinic; however, we found no evidence of cleaning schedule available at the clinic. Clinical staff were provided with uniforms and were seen to be bare below the elbow.

During our inspection, we observed two treatment rooms where handwashing facilities were available but no handwash gel was provided. There were no dispensers for hand sanitiser throughout the clinic.

The flooring was tiled and furniture was made of wipe‑clean materials. There were processes in place for the disposal and collection of clinical waste, and we saw this in action during our inspection, however there was evidence of overloaded clinical waste and sharps bins in both the consulting and treatment rooms. All clinical and non‑clinical areas were visibly clean, free from clutter and had suitable furnishings which were clean and well maintained. This included all consultation and treatment rooms.

Medicines were not always kept secure or stored safely. Medicines were stored in the treatment room, which only staff could access. The provider’s policy stated that only the management team knew the treatment room access code. However, during our inspection, the door was open and staff told us that all staff could access the room. Staff monitored and recorded the medicines fridge temperature twice daily.

We found concerns with storage arrangements in the second‑floor medical supplies room. The room was unlocked, overcrowded with medicines and intravenous fluids, and staff had not stored items safely or securely. Staff also stored boxes of medical supplies directly on the floor. The provider addressed these issues after our first inspection visit.

The provider did not always manage medicine stock in line with best practice. We found several expired medicines, including an expired medicine in the emergency medical bag. We also found boxes containing assorted medicines labelled in foreign languages, staff, including senior staff, could not identify these medicines or explain their purpose. Staff had not disposed of expired medicines appropriately and had placed them in general waste. These was immediately pointed out to the medical director, and he immediately disposed of all of them using appropriate medicine disposal kit.

Several clinical sharps bins were in use, but staff had not labelled or dated them, and some were close to their fill limit which increases the risk of accidental needlestick injuries. Although an emergency oxygen cylinder was available, there was no oxygen mask. This meant staff could not use the oxygen safely or rely on it in an emergency. We also found an empty medical gas cylinder stored alongside cylinders that were available for use.

We were not assured that leaders had effective oversight of medicines management or a consistent approach to medicines optimisation. We found several medicines stored in cupboards that staff, including the clinical lead, were unaware of. Staff did not follow a consistent approach to antibiotic prescribing, and we saw no evidence of a clear, evidence‑based strategy that supported antimicrobial stewardship principles. The overuse of antibiotics can lead to antimicrobial resistance and put patients at risk of adverse effects. The provider’s policy required clinicians to document a clinical justification when prescribing antibiotics for low‑risk procedures. However, we did not find evidence that clinicians had done this. Clinicians also did not consistently document follow‑up interventions used to determine the duration of antibiotic treatment in patient records. Medicines supplied for patients to take home did not meet legal labelling requirements and there was no record of who prepared and checked the medicines.

Patient records contained inconsistent information. Patient records we reviewed did not always show which medicines clinicians had prescribed or supplied for patients to take home. We could not always find a clear prescription record that met legal or the provider’s own policy requirements when supplying medicines to take home.

The service did not have an effective process for receiving, disseminating and actioning patient safety alerts.