Wimpole Clinic (Manchester)

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

This is the first assessment for this service. The key question was inspected but not rated. Some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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.

We did not look at Learning culture during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safe systems, pathways and transitions during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safeguarding during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Involving people to manage risks during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safe environments during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safe and effective staffing during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Several infection prevention and control (IPC) concerns were identified relating to governance, staff knowledge, environmental hygiene, equipment management, and clinical assurance.

Staff could not identify the IPC policy, and evidence of IPC training was not available during or following the assessment. The service also lacked a formal clinical incident reporting system. While management stated incidents were documented and reported to the London office, onsite staff had limited understanding of how incidents were investigated, escalated, or used to support learning, improvement, and risk management.

Sharps management was not always safe. A sharps’ bin was full and undated, preventing assurance that they were managed in line with IPC standards.

Sterilised instruments and a small steriliser were found in the medication and stock room. Management acknowledged the steriliser should not have been onsite and subsequently removed it. Although the provider stated that only single-use instruments were now used, limited evidence was available to demonstrate the steriliser had been appropriately approved, validated, maintained, or risk assessed. Following the assessment, the provider confirmed that no in-house sterilisation was undertaken, all instruments were single-use and disposable, and no sterilisation records, policies, or assurance documentation existed.

Environmental hygiene standards required improvement across several clinical areas. Theatres 2, 3, and 4 lacked complete cleaning records, contained visibly dirty equipment and storage areas, and showed evidence of poor housekeeping. Additional concerns included unsecured Control of Substances Hazardous to Health (COSHH) cupboards, an uncapped drain, unsecure emergency cupboard keys, rusted wheels on equipment, and a lack of evidence of portable appliance testing

(PAT) testing for some portable electrical equipment.

Stock management arrangements were weak. Records did not adequately track stock locations, balances, staff accountability, stock reconciliation, expiry dates, or supplier details. Documentation contained inconsistencies, incomplete entries, and duplicate records, limiting assurance over stock control and traceability. This was a breach of good governance. This was a breach of good governance.

When asked, the provider did not supply evidence that equipment had been appropriately maintained, serviced, or cleaned.

Following our escalation of concerns to the provider, significant improvements were observed during a follow-up assessment on the 22 July 2026. The steriliser and previously sterilised equipment had been removed, a deep clean had been completed, and environmental cleanliness had improved substantially. Staff demonstrated appropriate IPC practices during an observed procedure, including the use of single-use instruments and appropriate PPE.

The provider submitted IPC audit results showing overall compliance of 97.6% in June 2026 and 98.9% in July 2026 for the Manchester clinic, although it was unclear whether the June results related solely to the Manchester location or all Wimpole clinics.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs.

Staff did not consistently follow safe medicines management practices for the transport, storage, supply, administration, record keeping and disposal of medicines in line with recognised standards and national guidance.

The provider had a basic process for transporting medicines and procedure kits; however, it did not clearly define responsibilities, stock reconciliation, audit trail requirements, management of returned medicines, incident reporting or assurance processes. As a result, the provider could not demonstrate effective governance, accountability or traceability of medicines across sites. This was a breach of good governance.

A review of 33 surgical drug sheets identified significant record-keeping concerns. Most records were not countersigned, raising questions about document authenticity and accountability. Two records contained different Wimpole Clinic Ltd location stamps instead of the Manchester clinic stamps, 1 record was out of date (2020), and 2 lacked patient addresses. None related to patients treated at the Manchester clinic.

The Medicines Formulary and Prescribing Policy contained significant governance gaps. It did not identify a Medicines Lead, lacked comprehensive controlled drug procedures, medicines storage requirements, incident reporting arrangements, audit processes, competency requirements or references to relevant legislation and guidance. The document also lacked version control, review dates and a named owner. Arrangements for emergency medicines and expired medicines were insufficient, and parts of the policy appeared incomplete. This was a breach of good governance.

An expired medicine was found in stock during the assessment, indicating inadequate stock monitoring and creating a risk that out-of-date medicines could be used.

Pre-medication medicines had been repackaged into smaller quantities without evidence of appropriate authorisation or governance controls. The provider could not demonstrate assurance regarding medicine identity, expiry dates, integrity or traceability. Tablet splitting and subsequent repackaging were also identified without documented clinical justification or oversight. This was a breach of good governance.

Although records showed the procurement of 2 uncommon medicines for this particular service, no documented rationale was available to justify stockholding, limiting assurance that procurement was aligned to service needs and prescribing practice. This was a breach of good governance.

Staff reported that surplus pre-medication stock, including partial packs and medicines returned following procedures, had been transferred from London to Manchester. The provider was unable to demonstrate a complete audit trail or appropriate transfer, receipt and reconciliation records, limiting assurance regarding traceability, accountability and regulatory compliance. This was a breach of good governance.

Invoices showed the purchase of medicines and consumables; however, deliveries appeared to have been made to the London site, with limited evidence to demonstrate what stock was subsequently allocated or transferred to Manchester. This reduced assurance regarding stock control, audit trail integrity and cross-site traceability. This was a breach of good governance.