London Aesthetics and Regenerative 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

We looked for evidence that people were protected from abuse and avoidable harm.
At our last inspection in October 2023, we rated this key question as Requires improvement. At this assessment, the rating has not changed, and we rated this key question as Requires improvement.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
People felt supported to raise concerns and felt staff treated them with compassion and understanding.
The manager encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.
There were systems in place for processing information relating to new patients. Referrals and test results were managed in a timely way. All patients were informed to share details of their care and treatment, with their registered NHS GP on each occasion they used the service. Where patients declined to do this, the provider had a safety netting system, to ensure any positive test results were shared with the patient’s GP.

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 in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.
Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The service provided treatment for patients over 18 years and patients were informed that accompanying children were not allowed on the premises. There were systems and processes to ensure this was understood by new patients before attending their first appointment.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Emergency equipment was available and maintained. The practice was equipped to respond to medical emergencies and staff were suitably trained in emergency procedures.
Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.
There was an Automated External Defibrillator (AED) accessible to the service, and this was incorporated as part of their emergency response procedure. Patients were advised on risks and actions to take if their condition deteriorated. The provider gave patients after-care leaflets once treatment had been given and ensured the patient knew who to contact if there were any concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
There were contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.
The last fire risk assessment was carried out by an external contractor on 17 October 2024. The fire system was inspected regularly; the fire extinguishers were checked and there was a record of fire alarm checks. The service carried out regular fire drills.
Portable appliance testing was carried out on 4 June 2025.
The practice had an up-to-date legionella risk assessment (3 September 2024) in place and regular water temperature checks had been carried out. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings). The practice had carried out internal annual risk assessment reviews.
There was a business continuity plan in place which was monitored and reviewed.

Recruitment checks were not carried out in accordance with regulations prior to employment. For example, the three staff files we reviewed showed that references (satisfactory evidence of conduct in previous employment) and appropriate health checks (satisfactory information about any physical or mental health conditions) had not been undertaken prior to employment for all three staff. Interview notes were not kept in three staff files. A contract was not signed appropriately. A passport or evidence of the right to work in the UK was not kept in the staff file available for staff.
Disclosure and Barring Service (DBS) checks were not always undertaken appropriate to the role where required. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable. For example, we noted that a healthcare assistant (HCA) and aesthetic practitioner had received a ‘basic’ DBS check which was not appropriate to their role.

Staff who acted as chaperones were trained for the role. However, they had received a ‘basic’ Disclosure and Barring Service check (DBS check), which was not appropriate to their role and an appropriate risk assessment was not completed.

Shortly after the assessment, the service informed us that they were going to process applications for DBS checks at the appropriate level.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.
There were a range of clinical and non-clinical roles within the service. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

Feedback from people who use the service, was positive in relation the cleanliness of the environment.
The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
The practice had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.
The environment was noted to be clean and tidy during our onsite visit, and all appropriate personal protective equipment was available for staff to use.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.
Our clinical record review showed that there was a lack of information in some consultation records. We reviewed 13 clinical records. Consultation notes were scanned, and records were stored electronically on a secure network. In one consultation, a licensed medicine was used for an unlicensed indication, and a second off-label medicine was prescribed. However, the consultation notes did not document whether the risks associated with off-label use were discussed with the patient. Although a standard consent form was completed, it did not specifically reference the use of off-label medication. There was no clear evidence in the consultation record to confirm that informed consent, including a discussion of the associated risks, had been obtained.
People knew what to do and who to contact if they experienced any unexpected symptoms.
Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.
Medicines were stored appropriately in a locked medicines fridge. Temperature recordings were taken in line with the provider’s cold chain protocol, and no concerns had been identified.
Staff regularly checked the stock levels and expiry dates for all medicines including emergency medicines.
The service stored medical gases, such as oxygen, safely and completed the required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls.