The Fat Loss Centre

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

The service did not have processes in place to log and learn from incidents. People were not protected and kept safe as the service did not use safety checklists. Staff did not understand and manage risks well. The facilities met the needs of people; however not all equipment was clean, well-maintained and any risks mitigated. Not all staff had employee files, and therefore there was no evidence that all staff had been appropriately trained. Staff did not manage medicines well or keep accurate records.

This was the first assessment of this service, and we have rated it as inadequate. This meant people were not safe or protected from avoidable harm.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive culture of safety and did not use clear processes and procedures to record, log and investigate incidents and complaints. Lessons were not learnt to continually identify and embed good practice.

The service did not keep clear and accurate records of incidents and complaints. During our onsite assessment we requested to see an incident log, but a competed one was not available and there were no investigations into incidents to review. During conversations with staff, we discussed an incident regarding a post-surgical infection, however the registered manager told us there had only been one incident since registration and told us about a different incident where a patient fainted post operatively. We were not assured all incidents were logged, action taken to keep patients safe and lessons learned. This meant there may have been incidents that had not been recorded or investigated leading to failures in keeping patients safe. For example, we observed a bag of fluid that had been prepared and left unused on the countertop from the week before the assessment. It was unclear who had placed it there and whether it had been prepared with medication. There was an increased risk of cross contamination, medication instability and the fluid bag had not disposed of appropriately. This was not considered an incident and logged. We were not assured staff followed the providers incident reporting protocol by reporting incidents of all risk levels.

The registered manager told us learning was disseminated to staff through staff meetings. The minutes we reviewed were not detailed and did not share any learning. For example, the meeting minutes sent to the CQC after the onsite visit, were from the meeting following the CQC assessment. The did not detail any of the action taken since the assessment to improve the service and what lessons had been learned. Therefore, we were not assured learning from incidents was shared with staff to ensure they did not happen again. The registered manager was not able to identify themes and trends from incidents and complaints, and we were not assured learning from events had been used to directly improve the service.

The service did not work well with people to establish and maintain safe systems of care. Staff did not manage or monitor people's safety.

The service did not use a surgical checklist and there were no formal systems in place for documenting the interventions undertaken. A white board was used to document information during the surgery. A photograph of this was sent to the registered manager, by the surgeon, to upload to the patients notes. However, the patients name or reference number was not written on the board meaning the wrong notes could be uploaded to the wrong patients' file. We requested to see the list from the previous day's surgery to review against the pictures. The service was not able to provide this as they did not keep clinic lists. Therefore, we were not assured the service would be able to identify and access information about a patient in the case of an emergency. Following our assessment the provider developed and introduced a surgical checklist to help keep patients safe. We were unable to assess if this checklist was used consistently and if compliance with it use was audited as this took place following our onsite visit.

The whiteboard showed the service undertook one set of observations during the procedure and one set of observations after the procedure. There was no evidence on the whiteboard, or pre-operative documentation of pre-operative observations being taken. This meant the operative team did not know the patients baseline observations and may not identify a deterioration in the patient or take appropriate action.

There was no record of formal risk assessments of patients being carried out to identify contraindications for surgery. The surgeon and registered manager could articulate what they would look for, but this was not a written process for all staff to follow.

We were told no medical emergencies had occurred since the clinic was registered. In case of an emergency, we were told staff would call 999. Staff told us where the ambulance would be able to park so the patient could be transported while maintaining their privacy and dignity away from a busy shopping area.

As part of the consultation with all patients before surgery, staff told us potential issues around the patient's underlying psychological health and whether the procedure was appropriate would be discussed and assessed. During the assessment we observed a consultation with a patient prior to surgery. The surgeon did not consider the patient to be a suitable candidate for the surgical procedure, however there were no further discussions around psychological heath of the patient and the clinician discussed alternative (non-invasive) treatment.

Patients were given a discharge letter following their procedure with post operative care instructions. The discharge letter did not give detailed directions about medications supplied to them which meant patients may not take the medication correctly. An out of hours contact number was provided should the patients need to contact the clinic, and patients were followed up the next day with a telephone call following the procedure. However, this was not part of a formal written process for staff to follow which meant a patient might not receive a follow up call if the staff member was not aware this was part of the process.

The service did not always signpost patients to other services for additional support. Staff told us they had received safeguarding training however this was not always evidenced in staff files. The provider did have a process in place to share concerns quickly and appropriately.

The service did not have a safeguarding children’s policy, and the provider was not registered to see patients under the age of 18. The registered manager told us they would ask to see identification for younger service users to ensure they were over 16 years old and would be seen with a responsible adult. There was no clearly defined inclusion/exclusion policy to state what procedures younger patients could undergo. The service did not have clinic lists of patient’s names and procedures to review and it was not clear if younger patients had been considered for procedures that were part of a regulated activity.

Since the inspection, the provider has told CQC that the service does not undertake procedures for people under the age of 18.

The service had a safeguarding adult’s policy. This was in date and referenced national legislation. It set out safeguarding definitions and a process for staff to follow. We saw a safeguarding chart at the reception desk for staff to follow and staff we spoke with knew how to raise concerns. At the time of our assessment the service had not made any safeguarding referrals.

The registered manager was the safeguarding lead for the service and was trained to level 3 in adult’s safeguarding which we observed in the staff file. Staff members were trained to level 1 or 2 depending on their role as outlined in the safeguarding policy. We saw the training certificates in the employee files for the administrative team, however safeguarding certificates were not present in the clinical staff files we reviewed.

Clinical staff we spoke with were aware of the potential for patients to be persuaded by others to undergo the procedure and demonstrated an awareness of body dysmorphic disorder (BDD). However, there was no information available at the time of the inspection to signpost patients to additional support. The provider told us there was a poster for the Body Dysmorphic Disorder Foundation displayed behind the front desk, but inspectors did not see this poster during the inspection, nor did staff signpost them to it when discussing BDD. Furthermore, the BDD notice provided did not include an email address for service users to contact. Given the sensitive nature of BDD, patients may not feel comfortable being signposted to a poster in the reception area rather than being offered individual leaflets or information within the privacy of a consultation.

A chaperone could be requested, and posters were displayed to inform patients of this however, on the day of our assessment, there were no female member of staff on duty and therefore a female chaperone was not available. It was not clear how the service would offer a female chaperone on the day of the assessment. Following the inspection, the provider told us patients were asked to confirm if they required a chaperone at the pre-operatively and arranged as needed However, if a patient changed their mind on the day of the procedure, a chaperone might not always be available.

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

The patient's initial consultation with the service was not with a clinician and a clinical assessment was not undertaken until the day of the procedure when the patient met the surgeon. Patients could, upon request, meet a surgeon at their initial consultation but we were told this was not the usual practice. This meant patients may arrive expecting a surgical procedure that it was not safe to proceed with.

The provider did not undertake formal written risk assessments for patients as part of a pre-assessment to ensure it was safe for the patient to undergo the procedure. There were no set criteria for which patients the service would or would not accept. For example, there was no written criteria to assess whether an individual's body mass index score would make the procedure unsafe. Staff we spoke with were able to verbalise risks, such as the risk of treating a patient with a hernia, however, this was only assessed at the consultation with the surgeon just before the procedure rather than a pre-assessment. Patients who were taking blood thinning medication were required to request clearance from their specialist, for example their cardiologist, in order to stop taking medication before the procedure. There was no formal procedure for staff to follow to check for specialist approval and was reliant on individuals' knowledge to ensure these checks had been made and documented. The service did not have a formal process to assess patients' mental health which meant, people may not have the support in place to make decisions about treatment and we were not assured patients suffering mental health conditions would be appropriately assessed.

Staff did not always take patient observations which meant staff were not always monitoring patients effectively to assess whether they were deteriorating. The service did not use a clinical checklist, and we were not assured patients were monitored in a safe way. The whiteboard showed the service undertook one set of observations during the procedure and one set of observations after the procedure. There was no evidence on the whiteboard, or pre-operative documentation of pre-operative observations being taken. This meant the operative team did not know the patients baseline observations and may not identify a deterioration in the patient or take appropriate action.

During the inspection the registered manager told us they would ask for identification to check the age of young patients to ensure they were over the age of 16 years. However, the provider was registered to see adults 18-65 years of age. Therefore no one under the age of 18 should be seen or treated for a regulated activity.

Since the inspection, the registered manager has told us the service checks the identification to confirm they were over the age of 18.

The service did not always detect and control potential risks in the care environment. Staff did not make sure that equipment supported the delivery of safe care.

The service reported they did not use single use instruments for surgical procedures and were decontaminating and sterilising surgical instruments they used onsite. We found they did not comply with the Health Technical Memorandum 01-01, which is national guidance explaining the management of decontamination and sterilising reusable medical devices. We reviewed the equipment used for decontamination and found items missing, such as a magnifying glass used to inspect instruments to ensure all items were clean. The registered manager told us nursing staff were responsible for decontaminating equipment. On the day of our assessment there were no members of nursing staff, and it was not clear how equipment would be cleaned. The service did not have a designated authorised person to perform checks and validate the decontamination process. During the assessment we raised these concerns to the provider. Following the assessment, the provider told us they would use an external provider to decontaminate equipment and sent evidence of a service level agreement that was stated to now be in place. As this action took place after our assessment we were unable to confirm if equipment was being decontaminated by the external provider.

During the assessment, we observed adhesive tape had been applied to the operating table. This adversely impacted the ability to clean the operating table between procedures and introduced an infection risk to patients.

The oxygen cylinder onsite was small and could potentially run out if prolonged use was required for a deteriorating patient impacting on patient safety.

The theatre was large, spacious and compliant with Health Building Number 00-09, this is infection control in the built environment guidance. We saw fire extinguishers were in date and easily accessible. There were lift facilities and a wheelchair and evacuation chair if required. The registered manager had received training on how to safely use the evacuation chair.

The service did not make sure all staff were qualified, skilled and experienced. The service did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The service was not compliant with their recruitment policy. We reviewed staff files and found not all had completed documentation to show training, qualifications, previous employment, appraisals and the self-declaration form for new applicants. Not all members of staff had an employee file. For example, on the day of the assessment, one doctor in theatre did not have a staff file. We were advised they had recently been employed. We were not assured they had completed the mandatory training or had the skills and experience required.

All staff were employed by the service and did not work under practising privileges. Locum surgeons were used on occasion. There was no policy or process in place for how locum staff would be inducted, what qualifications and skills they had, or log of locum staff used by the service. This meant there was no assurance that only appropriately trained staff were employed by the service.

We were not clear how many employees the service employed. We were given different numbers throughout the assessment and not all staff had an employee file. This meant it was unclear who should have an employee file with documented evidence of employment, references and training and what staff were expected to be on shift at any given time.

The service did not have a documented process detailing what staff were required to safely carry out the surgical procedure. The service did not use a staffing model to assure themselves they had the right number of staff working when procedures were carried out. We were told there was one nurse, and one healthcare assistant employed, neither of them were working on the day of our assessment when procedures were being undertaken. Therefore, we were not clear whether there should have been a nurse or healthcare assistant on site to be fully staffed.

During the inspection we were told by the registered manager that all staff had a one-week induction programme which included mandatory training however the provider did not have a documented induction programme. The induction checklist we saw included fire evacuation and waste recycling but not where medicines were stored or training on equipment used. Therefore, we were not assured the induction covered all aspects new staff might be required to know and understand to safely undertake their roles.

Since the inspection the registered manager has provided an induction checklist that includes training of equipment, but not the storage of medicines. The nursing and HCA checklist is a combined checklist and does not differentiate between the responsibilities of each role, for example, a registered nurse’s role in anaphylaxis would differ from a HCAs due to legal scope of practice in administering medications including for example oxygen and adrenaline

Staff files did not include qualifications on the use of specialist equipment to undertake the minimally invasive liposuction procedure. The provider did not have a policy in place detailing what training and skills were required to undertake the procedure. We were not clear who within the service was able to undertake the procedure as during conversation with the staff and registered manager, the information was inconsistent. The surgeon we spoke with was unsure about the qualifications of the nursing staff meaning they were not assured staff had the right qualifications to assist during the procedure.

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

The areas we observed were visibly clean and soft furnishings were wipeable, however in theatres adhesive tape had been applied to the operating table which introduced an infection risk to patients. The provider had an infection prevention and control policy in place which was reviewed annually and referenced national guidance and legislation.

The provider stated he had carried out an infection prevention and control (IPC) audit dated 03 March 2025; however, this was not available to review at the time of the assessment. The audit which was sent to CQC after the inspection noted that all equipment in the theatre was in a good state of repair and did not reference the operating table with the adhesive tape on. Therefore, we were not assured the audit reflected the environment or was carried out on the date it referenced. The audit refers to cleaning logs. We requested to see cleaning audits, but these were not provided, and we were referred to the IPC audit.

The service sterilised and decontaminated equipment onsite, however we found that this was not compliant with national guidance and posed a risk of infection to patients. Following the assessment, the provider returned to using an external provider to decontaminate equipment. However, as the service has suspended it's regulated services following our inspection, this cannot yet be verified.

The service used different bins for the disposal of waste, however we observed the disposal of personal protective equipment in the wrong bin posing an infection risk. The service used sharps bins, but they were unlabelled and not dated. This was not in line with best practice or national guidance.

Patients were given a prophylactic dose of antibiotics before surgery and were given antibiotics to take after their procedure to reduce the risk of infection. However, there was no risk assessment or policy in place to show how the service had arrived at the decision to prescribe a prophylactic dose. This meant patients might be taking antibiotics unnecessarily.

During the assessment we asked to see the hand hygiene audits. We were advised they had not been undertaken yet. This meant in the 6 months the provider had been registered, hand hygiene had not been observed and audited. Following the onsite assessment the provider submitted a copy of the hand hygiene audit that had been carried out. This gave the date of the next audit, in two months. It assessed individuals practice and noted an area of improvement and what action had been taken to improve.

During the onsite assessment we observed staff were bare below the elbow in line with the provider's infection prevention and control policy. We saw the 5 steps to hand hygiene poster displayed and hand sinks for staff to wash their hands.

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

Medicines were not stored in line with national guidance. Bespoke intravenous (IV) fluids containing medicines to be used during procedures were prepared in advance in the morning. However, they were not labelled to indicate what medicines were in each fluid bag. Bespoke IV bags containing medicines for routine use and IV bags for emergency use could not be distinguished. There was a risk that patients could be administered the incorrect medicines during the procedure or in an emergency. We saw IV fluid bags containing medicines stored on a radiator. This was used to warm the solutions before administration. However, they were not stored securely, and we witnessed an IV bag fall on the floor. There was an increased risk of contamination of the IV bags which could lead to infection in patients. Staff told us that any unused fluid bags at the end of each day would be disposed of. However, we found an unused fluid bag dated from the week prior. There was an increased risk of contamination and medicine instability in the bag. These practices where not underpinned by the services policy.

Medicines were not always used in line with manufacturers guidance. We saw that single use medicines used to prepare solutions for infusions were not discarded after use. Instead, they were used to prepare multiple infusion bags. This put patients at greater risk of harm due to contamination risks.

Medicines including controlled drugs were stored in a locked medicine cabinet and in the fridge. However, they were not always stored safely. For example, we found pain relief medicines stored in the packages for a different medicine. Furthermore, we found controlled drugs that staff could not account for. There was an increased risk that patients could be given the incorrect medicine.

Patients’ medicines and medical history were reviewed by clinical staff and consent obtained for the treatment before the procedure. We saw that each patient’s allergy status was checked before procedures.

However, staff did not always keep detailed records of patient’s care. Records were not always clear, contemporaneous, and easily available to all staff.

The service routinely supplied medicines for post-surgery infection prevention, but these supplies were not made in line with legislation. They were not supplied in person specific labelled packages containing information on how to safely take them. Patients were not supplied with the medicines patient information leaflet (PILs). We were not assured people received all the required information to safely take their medicines.

Records of medicine supply and administration were not recorded in line with the legislation. They were not accurate, complete or up to date. These supplies were not clearly recorded in patient files.

Furthermore, the process for recording the administration of medicines given to patients during procedures was not robust. This information was captured on a whiteboard during the procedures, photographed, then uploaded to patients’ records. However, the service was unable to produce these records of patients who had recently used the service.

The service had a medicines management policy. However, the policy did not fully reflect all areas of medicine management in the service. For example, we did not see any information on the expectations of staff on how to safely manage IV fluids and medicines. Furthermore, the person responsible for the implementation of the policy no longer worked at the service. The policy had not been updated to reflect this.

The service had access to emergency medicines including adrenaline, IV fluids and oxygen. However, there was no clear policy for the management of these.

There was no process to identify, assess, monitor or improve medicine related risks in the service. The service could not demonstrate how they were assured that the safe handling and prescribing of medicines was being done in line national guidance. However, the service had a system in place to manage and act upon patient safety alerts. Patient safety alerts are official notices, (which may include medicines recalls) giving instructions on how to prevent risks which might cause harm to patients.