Seymour Clinic

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 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. We also ensured that people’s liberty was protected when it was in their best interests and in line with legislation.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

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 understood their responsibilities to raise safety incidents, concerns and near misses and were encouraged to do so by senior leaders. However, not all staff knew how to access the service’s incident reporting form and opted to verbally communicate concerns with the operational or registered manager. This was not in line with the service’s serious incidents policy and incident reporting protocol, which stated that the person who was directly involved in or witnessed the incident should complete an incident form and submit it to the operational manager via email. This matter was escalated to the operational manager, who reported access to the form would be shared with all staff.

The service reported that no incidents had been submitted via the services incident reporting form. However, during the assessment staff spoke to us about cases we would expect to be reported. An example of this was a breast augmentation case being cancelled due to lack of communication around the size of implants to be used. This should have been reported and investigated. This meant the service could not demonstrate that incidents and concerns were consistently recorded, reviewed and used to improve safety.

Senior leaders told us there had been no never events or serious incidents between April 2025 and April 2026. Never Events are serious, largely preventable patient safety incidents that should not happen if all available preventative measures have been used.

The service gave us information where they had learned from incidents and made appropriate changes in response. For example, the service noted delivery delays of a particular implant which could only be sourced from overseas. Delivery delays had resulted in cancelled procedures. To mitigate the risk of cancellation and poor patient experience, the service had sourced a more reliable transport company at higher expense.

Staff understood the duty of candour. They knew how to be open and transparent, and how to give patient and families a full explanation if and when things went wrong. The duty of candour is a regulatory duty which relates to openness and transparency. There were no incidents reported to meet the threshold for the duty of candour.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The service was opened approximately 8 times a month depending on the number of patients booked for surgical cases. There were regular consultant doctors who specialised in multiple cosmetic surgical procedures. This included but was not limited to face lifts, breast surgery and surgical changes to female genital.

The service provided cosmetic surgery for self-funded patients. Patients accessed the service through 1 of 3 operating models. The first operating model required a self-referral by the patient via the services website or the customer services team, in which a doctor from the service was allocated. The second operating model involved doctors working with the service to bring their own patients and booking the theatre. The last operating model involved external companies with separate a CQC registration bringing their own surgeon and patient to use the services facilities and equipment.

Patients had an initial consultation with their allocated surgeon. This involved collecting past medical history and discussing the risks and the patient’s expectations of the procedure. Once patients had been accepted for the procedure, they were able to book a suitable date and time. The operational manager tracked consultations and appointments to ensure treatments were completed in a timely manner and enabled a cooling off period before going ahead. This allowed the patient to take their time in deciding to have surgery or not.

All procedures were undertaken as day cases, with patients being discharged on the same day. Depending on the procedure patients received either local or general anaesthesia. An anaesthetist was present at all surgeries requiring general anaesthesia. Surgeons also had access to other doctors if a second opinion was required. All staff were aware of the process if an emergency occurred which required patient transfer to an NHS Hospital.

Patients were given follow up information and appointments for aftercare prior to discharge, with contact details for their surgeon if they had any concerns. Leaders also reported patients could contact the clinic directly, even on days the service was not opened for surgical procedures.

Patient notes were stored securely. They were detailed in content, and all staff could access them easily. The service used an electronic patient records (EPR) system to book patients and manage all their records prior to their surgical procedure and after. All surgical notes were paper; however, these were scanned onto the EPR system within 24 hours of the procedure, with the hard copy being shredded.

When patients had their appointments cancelled at the last minute, managers made sure they were rearranged as soon as possible. Staff told us appointments were rarely cancelled, however, if they were, the next available slots would be offered.

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 safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service did not provide care or treatment for children or young adults under 18 years old. However, the service made sure all staff received training specific for their role on how to recognise and report abuse for adults and children. Overall staff compliance with safeguarding adults and children training level 3 was 94%, with one member of staff in the process of renewal at the time of assessment.

The service had a safeguarding adult’s policy which was in date for review and all staff had access to. The service had a named safeguarding lead and all staff we spoke with knew who the safeguarding lead was and how to contact them.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and knew how to work with other agencies to protect them in line with the service’s safeguarding policy. We were told how staff would escalate any concerns to the safeguarding lead and local authority, if necessary, in line with the service’s safeguarding policy.

All patients were offered a chaperone during consultations and were encouraged to bring a chaperone to support the patient with discharge after a procedure. In lieu of appointment of a chaperone the service had a chaperone waiver for patients to sign.

Relevant recruitment checks had been completed for all staff who had commenced working for the provider within the last 12 months. These included a disclosure and barring service (DBS) check and professional registration checks.

The service worked well with people to understand and manage risks.

Staff completed risk assessments for each patient on arrival, using a recognised tool, and reviewed this regularly, including after any incident. We reviewed 7 patient records which showed good compliance with risk assessment completion. Risk assessments included but were not limited to, the patient’s suitability for the procedure, which included, medical history, observation using a nationally recognised tool and venous thromboembolism (the risk of getting a blood clot in the vein).

Staff used a nationally recognised tool to identify deteriorating patients. The National Early Warning Score (NEWS) was used in the service to identify patients at risk of deterioration. NEWS charts reviewed during the assessment were completed and scored appropriately with no need to escalate to the medical team.

The service had an in date medical emergencies policy for the management of cardiac arrest, choking and anaphylaxis (this is an allergic reaction) and transfer of deteriorating patient policy.

Staff used the World Health Organisation (WHO) safer surgery checklist in theatres, which was designed to prevent avoidable mistakes. In patient records we reviewed we saw WHO safety checks were undertaken as per national guidelines. Staff also completed venous thromboembolism (VTE) risk assessments in the notes we reviewed onsite. Audit data showed 100% compliance in both areas between the months of January and March 2026.

Swab and sharps checks were also completed after each surgical procedure to ensure all items used were accounted for. Audit data showed 100% compliance in both areas between the months of January and March 2026.

Staff communicated with patients and their families, so they understood their care and treatment, including finding effective ways to communicate with people with communication difficulties. Staff informed us that translation services were available for people whose first language was not English. All patients and families we spoke with told us they were involved with the decision making about their treatment.

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.

The service had suitable facilities to meet the needs of patients. The clinic had a reception, waiting area, refreshment room, 2 consultation rooms, 1 theatre and a recovery area with 2 bays. The design of the clinic allowed for wheelchair access as all areas were on 1 floor. However, we noted a wall in a corridor patients had access to, with water damage near a radiator. This was escalated to leaders who were aware of this damage which was caused by extensive rain. They reported that it had been escalated to the landlord of the building and the radiator was out of use until repairs took place. This had not been identified on the service’s risk register.

Access to the clinic was secure; however, we noted that access to the operating theatre was not restricted with controlled access. This was escalated to the operational manager, and they reported that there was a low risk of unauthorised personnel accessing clinical areas. This was because they always had somebody on reception, which had direct view of the door leading to clinical areas.

The theatre had a clean surgical scrub and preparation area to prepare for surgery. There was also a supply area with a range of in date sterile and single use equipment such as needles, syringes and dressings. All surgical instruments were accounted for after surgery and sent to an external company for cleaning and re-sterilisation, at the end of each day.

The service had enough suitable equipment to help them to safely care for patients. The theatre had appropriate surgical equipment that had been portable appliance tested (PAT). We observed a damaged cardiac monitor which posed an electrical risk due to exposed wiring. This was escalated to the operational manager who replaced the monitor immediately.

There was a fully equipped adult resuscitation trolley in recovery. The trolley included medications for anaphylaxis and an automated external defibrillator. Staff carried out daily safety checks of the specialist equipment including the resuscitation trolley when the clinic was open.

The service employed an external contractor to carry out electrical systems maintenance, fire safety assessments, water checks and portable appliance testing. Fire safety equipment was fit for purpose and in date. This included fire extinguishers, the alarm system and emergency lighting. The service also carried out a legionella risk assessment.

However, the service did not specify whether action had been taken in response to all the recommendations from the above risk assessments. The outstanding recommendations we noted included but were not limited to; introduction of a fire safety policy, undertaking a fire safety drill, display of the health and law poster and documentation of regular water temperature checks.

The service did not meet control of substances hazardous to health (COSHH) standards, which includes safe storage of products. During the inspection we observed cleaning detergent being left in an unlocked cupboard that was accessible to patients. This was escalated to the operational manager who reported that they would put a lock on the door to prevent unauthorised access.

Staff disposed of clinical waste safely. Sharps bins were labelled and used appropriately with no overfilled sharps’ bins seen in the clinic. There was a service level agreement in place with an external company for collection of clinical waste.

The service made sure there were enough qualified, skilled and experienced staff. However, the service did not supply evidence of practicing privileges or appraisal rates.

We observed doctors’ records with appropriate indemnity insurance and management reported that all doctors worked under practising privileges. However, the service did not have a policy for granting and reviewing practicing privileges and did not provide evidence of practicing privileges for all doctors working at the clinic.

The service had enough staff to keep patients safe. The service had 18 members of staff who worked on a bank rota when procedures were booked in. Staff included administrative staff, nurses, doctors and an anaesthetist who was also the registered manager

The operational manager accurately calculated and reviewed the number and grade of nursing staff needed for each shift. Staff were available according to the procedures planned.The manager could adjust staffing levels daily according to the needs of patients. In the event of any appointment cancellations, staffing could be rearranged and in the event of staff sickness the service used agency nursing staff. However, leaders reported that agency staff were rarely used.

Managers gave all new staff a full induction tailored to their role before they started work. Staff reported that a local induction was completed for all staff and documented on an induction checklist. During the assessment the service had a new member of staff who corroborated this.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of patients. Staff undertook yearly mandatory training modules facilitated by external training providers. Required training included topics such as life support, infection prevention and control, equality, diversity and inclusion and conflict resolution. Mandatory training compliance for all staff was 89% with one member of staff in the process of renewal at the time of assessment.

The operational manager reported that staff received yearly, constructive appraisals of their work in house or as part of their substantive NHS role. However, the service did not provide appraisal rate data. This meant that we could not be assured that all staff receive a yearly appraisal or were having conversations about career development and how it could be supported.

The service managed the risk of infection.

Clinical areas were visibly clean and had suitable furnishings, which were clean and well-maintained. The service had domestic staff to clean all areas of the clinic. Equipment in treatment rooms were cleaned by the therapist or clinical staff, before and after any treatments. We saw examples of cleaning records for the last 6 months and saw cleaning checks had been completed daily when the service was open.

Staff followed infection control principles including the use of personal protective equipment (PPE). Staff wore PPE in line with national guidance. Hand hygiene signage was displayed throughout the service, and we observed staff following hand hygiene procedures appropriately.

Staff received and kept up to date with infection, prevention and control training. Overall staff compliance was 94%, with one member of staff in the process of renewal at the time of assessment. Staff also had access to the service’s maintenance of asepsis during a surgical procedure policy and the scrubbing, gowning and gloving protocol.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines, including controlled drugs, were stored in secure storage areas with access restricted to authorised staff. The service kept medicines stored at the clinic to a minimum and we saw items were stored securely in cupboards and a fridge. All medicines we reviewed were in date. Staff monitored fridge temperatures daily to confirm fridge temperatures were within the range and we saw these were recorded.

Medical gases and equipment were checked regularly, in date and readily accessible to staff. Gases were stored away from flammable materials

We reviewed 7 patient medicines charts and found that all allergies were documented, and people received their medicines as prescribed. Staff followed systems and processes to prescribe and administer medicines safely.

We saw controlled drugs (CD) were stored, recorded, and handled appropriately with 2 nurses signing when controlled drugs were being given. The CD book was complete with no gaps or errors.

The service did not hold medicines to take out (TTO) but referred patients to their local pharmacy to pick up prescribed items.

We reviewed the service’s policy for the management of medicines which gave information on prescribing, storage, and dispensing of medicines, record keeping, adverse drug reactions and audits.

According to the policy the service should carry out a monthly audit of medicines stored at Seymour clinic. However, the service did not supply medicine audit data as requested, which meant we could not be reasonably assured medicine management was being monitored to identify risks or improve practice.