Wimpole Clinic (Manchester)

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This is the first assessment for this service. The key question was inspected but not rated. The service management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We did not look at Shared direction and culture during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Capable, compassionate and inclusive leaders during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led 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 have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Daily operational meetings were held each weekday, supported by executive, compliance, governance, medical, HR, legal, marketing, infection prevention and control, scheduling, doctor, technician and clinic-wide meetings. Staff demonstrated an understanding of how they worked collaboratively with other teams and locations to support patient care and service delivery.

Despite the established meeting structure, limited evidence was found that governance arrangements consistently translated into effective oversight of risk, performance and quality improvement. Several areas reviewed demonstrated weaknesses in escalation processes, action tracking, assurance mechanisms and organisational learning.

No serious incidents were reported during the review period.

The provider had received one complaint during the review period. However, records did not contain sufficient detail regarding the date, nature, investigation, outcome or lessons learned. Consequently, the provider did not demonstrate how they were assured that the complaint had been appropriately managed or that any resulting recommendations had been implemented and monitored to completion. This was a breach of good governance.

The audits provided for review were not sufficient to demonstrate assurance regarding quality, compliance or patient safety. Evidence of comprehensive audit programmes, action plans, monitoring arrangements and verification of improvements was limited. The provider failed to demonstrate that identified issues were consistently addressed, monitored and embedded within practice. This was a breach of good governance.

The management of risk, issues and performance was not sufficiently robust. The clinic risk assessment was not fit for purpose, as risks were categorised simply as low, medium or high without any documented methodology, rationale, supporting evidence or meaningful assessment of impact and likelihood. This was a breach of good governance.

Staff maintained access to the risk register (non-conformity register); however, the provider did not demonstrate that effective escalation arrangements operated across all organisational levels. Review of the non-conformity register identified 5 actions recorded since January 2026. All actions had been categorised as urgent; however, none had been formally signed off, dated or verified as complete. One action remained unresolved after 7 months. These findings raised concerns regarding governance oversight, accountability, action tracking and the organisation's ability to ensure risks were effectively managed and mitigated. This was a breach of good governance.

Records demonstrated that 1 doctor had been reminded on 5 separate occasions to sign an employment contract. Documentation reviewed included a recommendation stating that the doctor should be prevented from working until the contract had been signed. However, no evidence was identified to demonstrate whether that recommendation had been implemented, whether the matter had been formally resolved, or whether management approval and sign-off had occurred. This was a breach of good governance.

A review of surgeons' weekly meetings identified a lack of standardisation in both agenda structure and meeting content. No consistent format was used for discussion, presentation or reporting, resulting in variation in the information reviewed from week to week. Documentation was often incomplete and there was limited evidence that clinical outcomes, complications, trends or lessons learned were routinely reviewed. This was a breach of good governance.

Meeting minutes dated 14 May 2026 identified concerns regarding doctors leaving surgical procedures to undertake patient consultations. Staff reported that this practice contributed to delays, increased patient anxiety and additional pressure on technicians. This arrangement presented a number of potential risks, including interruptions to clinical procedures, reduced medical oversight, increased likelihood of error and infection, extended procedure times and communication failures.

Data presented at a meeting held on the 02 July 2026 demonstrated very low levels of documented patient follow-up activity. Of 80 review opportunities, only 1 review had been recorded, equating to a review rate of 1.3%. Patients are required to received 6 and 12 monthly reviews following their surgical procedures. This was a breach of good governance.

Our review of governance documentation identified widespread issues with document control and review arrangements. All 17 of the policies were overdue for review. Of the 30 clinical documents, 6 were out of date. Similarly, all 26 Standard Operating Procedures (SOPs) were overdue for review. Only 12 contained issue dates and only 7 included review dates. We saw 18 HR forms which were more than 1 year overdue for review. In contrast, all 22 patient information documents reviewed were current and compliant. This was a breach of good governance.

Several infection prevention and control procedures were not fit for purpose. The End of Day Theatre Cleaning and Infection Control SOP, Environmental Cleaning and Equipment Decontamination SOP, and Clinical Waste SOP lacked key operational and governance requirements, including clear responsibilities, cleaning and decontamination standards, competency assessment, audit arrangements, document control, and current legislative references. In some cases, documents were overdue for review, limiting assurance that infection prevention and control activities were supported by robust and current procedures. This was a breach of good governance.

Significant governance weaknesses were also identified within medicines and kit management procedures. The Protocol for Transferring Kits and Medications lacked clearly defined responsibilities, comprehensive record-keeping requirements, and adequate security and audit arrangements. Similarly, the SOP for Returning Medication did not clearly define the conditions for reusing returned medicines, authorisation requirements, stock reconciliation processes, or arrangements for investigating and escalating discrepancies. These weaknesses reduced assurance regarding the safe, secure and accountable management of medicines and equipment. This was a breach of good governance.

The stock control system itself contained incomplete and inconsistent records. Whilst Lot numbers, expiry dates and quantities were recorded, there were no running stock balances, accountability mechanisms for stock movements, reconciliation processes or data validation controls. The provider failed to demonstrate how they were assured regarding stock traceability, accountability and inventory. This was a breach of good governance.

Invoices were provided for 18 sterile hair transplant equipment packs purchased in December 2025 and February 2026. However, no evidence was available to demonstrate that these purchases related specifically to the Manchester clinic. Consequently, the provider did not demonstrate how they were assured regarding stock provision, allocation, traceability or availability of sterile equipment at the location reviewed. This was a breach of good governance.

Information governance arrangements included measures to support patient confidentiality. Patient consent documentation and staff induction materials clearly outlined staff responsibilities concerning the management and protection of confidential information. These arrangements provided reasonable assurance that confidentiality requirements had been communicated to staff and patients.

We did not look at Partnerships and communities during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Learning, improvement and innovation during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.