DrDucu London

On this page

• 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

We identified issues in relation to governance and assurance processes in the key question of well‑led, where we told the service it needed to make improvements. The service did not have clear governance, management and accountability arrangements to support the delivery of safe care and treatment. Although the service had a wide range of policies in place and these were accessible to staff, many did not contain a review date. While audits were in place, they did not always cover the most critical areas in sufficient depth or scale to meaningfully support service improvement.
 

However, leaders promoted a positive work culture based on equality, diversity and inclusion, but there was no shared direction. Staff were supported to speak up or raise concerns.

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.

The service did not have a formal strategy to support the vision for the service. The vision of the service was to provide competitively priced cosmetics and other healthcare services. There was an informal strategy to support the vision that managers told us about; however, this was not written down.
 

The service had a suite of policies, however some of the policies did not have a review date on them. The lack of review dates on some of the policies raised concerns about the effectiveness of the clinic’s governance arrangements.
 

Staff told us they worked in a supportive environment where there was mutual respect for each other’s culture and background. They said they helped each other out at busy times. One staff said, “I felt safe at work, sometimes I worked alone but I was very safe. The manager checked in on me and made sure I was okay.” Another member of staff who said they felt well supported said, “I could talk to the manager about how I was feeling; they took an interest and took actions if anything was needed.”

Leaders had the skills, knowledge and experience to lead effectively. Staff said there was consistent and visible leadership who regularly communicated with staff.
 

Staff respected the leadership team and spoke positively about collaborative work in all aspects of work. Staff told us the leadership of the service actively supported their career development. Managers ensured staff maintained and enhanced their skills and professional expertise through structured professional development, including funded courses, protected time to attend conferences, and access to relevant workshops. This demonstrated that the
service prioritised staff competence, capability and ongoing professional development.
 

Not all staff understood the remit of their roles and the scope of their responsibilities. Those responsible for medicines management did not fully understand their duties, and we found gaps and lapses in their knowledge and practice relating to safe storage of medicines.

The leadership of the service demonstrated an understanding of the challenges to quality of the service. The clinic manager told us there were systems to review the performance of leaders and to continually develop their skills and improve the service. This was done through professional development training courses, conferences and workshop attendance as evidenced by certificate of attendance in staff files
 

We spoke with both clinical and non‑clinical staff who told us they were happy with their manager and the leadership of the service. Staff said they did not have monthly supervision meetings with their managers; however, managers were approachable and supportive. Staff said they felt valued by the doctors and managers and that, managers were approachable and supportive. Staff told us leaders acted on staff feedback and comments to make
improvements. For example, the manager told us how they developed and managed the staff rota to ensure the clinic was staffed safely as a result of patient feedback, staff rotas were changed and compressed hours introduced as a result of staff feedback.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. However, there was not a formal process for staff to use a speaking‑up service at the time of our inspection. Staff we spoke with told us they did not need to use the freedom to speak up service as they had been able to raise concerns within their teams and to managers directly, and these concerns had been listened to and dealt with for example requested a compressed hours due to travelling long hours to work, which was granted by the management.
 

All the staff we spoke with told us they worked in an open culture were speaking up was encouraged and valued. The service had a whistleblowing policy. This policy applied to all individuals working at the service and outlined some of the concerns that staff could raise. The policy included details of timescales and feedback from the investigation of concerns, whilst reaffirming protection for staff speaking up and being treated fairly and without prejudice.
 

Patients were provided with information explaining how they could raise concerns and how these would be investigated. This information was contained in the patient guide, however we did not see nor observed this when onsite.

The service valued diversity in its workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Managers told us staff came from a range of different countries and had a range of ethnic backgrounds and experiences. Staff told us they were treated equally and fairly. They said they valued each other’s differences and worked together well as a team for the benefit of patients. Staff said they were able to work flexibly when they needed to attend important personal appointments.
 

The clinic manager told us there was a positive culture of equality, diversity and inclusion across the workforce and that there was diversity across staff groups that matched the diversity of the patient population. We were told training was available for all staff in equity, diversity and inclusion (EDI). This was a mandatory requirement for all staff. Training compliance data showed a 98% completion rate for EDI training.
 

There was a policy and standard operating process for equity, diversity and inclusion. The policy supported recruitment from diverse backgrounds. Staff were able to request flexible working arrangements, for example flexible working agreements to accommodate their personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their work such as varied start times at work and compressed hours for staff who live far from the clinic.

There was an informal and limited governance structure. The service did not have appropriate systems of accountability and good governance. Not all staff we spoke with during the Inspection were able to clearly articulate their roles and responsibilities within the service, they did not always act on the best information about risk to the service. The processes and systems of governance were not effective in supporting improvement and the safe delivery of the service. For example, there was no risk and governance oversight for medicines management
at the service.
 

The limited and informal governance process in place provided a structure for developing and learning; however, we saw no evidence of how this was shared with operational staff in any meaningful way other than a meeting where they were told what had happened and what the service would do about it. We saw no examples of any learning from incidents or actions completed following an incident.
 

The service had an audit programme covering a range of areas, but it did not demonstrate that audits were driving measurable or sustained improvement. Evidence provided showed only limited examples of completed audits, and the level of detail was insufficient to assure us that the programme was effective. Although some audits had been carried out, systems were not used well to monitor compliance or track progress over time. Audit outcomes had not been compared with previous results to identify trends, and there were no action plans setting out what improvements were required, who was responsible, or the expected timeframes for completion. This meant the service could not demonstrate how learning from audits was used to improve practice or assure ongoing compliance.
 

We noted that checks on the environment and infection prevention and control audits had taken place and records had been kept, but they had not been collated to demonstrate if there were themes or trends in issues requiring improvement.
 

There were limited and insufficient processes to ensure doctors working under practising privileges or the technicians who supported hair transplant surgery had the necessary skills, knowledge and experience, or were safe to work in the clinic.
 

The service was not signed up to receive Central Alerting System (CAS) safety alerts that helped ensure up‑to‑date guidance was followed. CAS alerts were web‑based safety alerts, including National Patient Safety Alerts sent to NHS and other healthcare providers. Following our inspection the provider submitted evidence to demonstrate that they were signed up to the National Patient Safety Alerts, device safety information and medicines recalls/notifications.
The service had a risk assessment folder, but this did not provide oversight of the main risks affecting the service. This meant the likelihood and potential impacts of a range of risks to the safety of the service were not clearly defined and consequently there were no mitigating actions.
 

There were meetings held at the clinic which were designed to cover incidents, complaints, safer recruitment and staff training. However, there was no evidence to demonstrate that these meetings were being used to foster good governance arrangements at the service. There were systems to ensure servicing of equipment took place within manufacturers’ guidelines as noted in the service contract and service records we saw at the clinic.

The service understood its duty to collaborate and work in partnerships so that services worked seamlessly for people. Staff and leaders understood the importance of working in partnership. For example, doctors shared information about the diagnosis of conditions that required treatments outside the scope of the clinic with patients’ GPs. We were told that if people were required to visit other health providers, the service provided information for them to take which explained the procedures they had undergone.
 

The medical director told us they engaged with local acute independent hospitals and other aesthetic/cosmetic clinicians through meetings and conferences. They discussed and exchanged clinical information on recent innovations to support their services. Patients told us the service had been recommended by their friends or had been identified through a web search. People confirmed they had been asked to confirm information about themselves, the procedure and their health prior to undergoing their planned procedure at the clinic. People said following their procedure, they had a further appointment booked with their consultant to review and discussed their progress.

The service focused on continuous learning and encouraged staff ideas for improving patient care. Staff told us there was a culture of learning and improvement within the service. They said the clinic’s CQC registered manager valued their contribution, abilities and professional expertise, and supported their development through funding for continuous professional development, including conferences and workshops.
 

Staff told us they were involved in developing the service to improve patient care. They felt managers were open to suggestions and acted on staff feedback. For example, managers agreed to amend pre‑assessment forms following staff recommendations.
 

There were no unexpected deaths or notifiable events at the clinic since its registration with the CQC in November 2025. Leaders understood their responsibilities to notify and share information with external bodies when these incidents occurred.