Pall Mall Medical 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 rated safe as requires improvement

We identified breaches of 2 regulations: safe care and treatment in relation to infection, prevention and control and fit and proper persons employed in relation to recruitment checks.

Although the environment was clean and clinical, it did not fully support effective infection prevention and control. The layout and use of sinks fell short of best practice standards, and the sterilisation process for reusable blades was not in line with the Health Technical Memorandum 01-01 (2016) guidance. Despite these issues, staff consistently delivered care in a way that made people who used the service feel safe, supported, and listened to. People who used the service reported feeling reassured throughout their treatment journey. Staff maintained a well-organised and visibly clean environment. They worked closely with people who used the service to uphold safe care practices, demonstrating a strong understanding of pain management and tailoring their approach to individual needs.

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 clear incident policy, reporting forms and a major incident plan covering clinical, environmental, operational and security risks. No formal incidents were reported in the past year. A previous inspection found incidents were often discussed informally but not recorded. However, staff and managers understood what counted as an incident which they told us was anything causing or potentially causing harm, injury, loss or disruption. This included clinical errors, near misses and safety issues. Staff gave examples and showed good awareness. Technician induction evaluations showed some staff needed more training in risk awareness. The registered manager told us this was because staff had not identified trip hazards and confirmed extra training had been provided.

Staff held daily check-ins and pre-surgery huddles to discuss plans. Updates were shared in a bi-monthly newsletter and a phone messaging app.

Despite the lack of formal incident records, we saw evidence of learning. For example, after recognising vasovagal fainting during FUT procedures, the service changed practice, so people lay face down rather than sat up during procedures. This reduced fainting episodes. We also observed learning from a missed blood pressure reading which led to planned spot checks to improve compliance.

Managers said they regularly reviewed what went well, identified areas for improvement, and explored ways to enhance the service.

People tended to find the service through social media or word of mouth. Head office then arranged an initial video consultation. If the person decided, they would like to go ahead with the hair transplant they would then be seen face-to-face at a chosen satellite clinic for a full assessment.

The office manager carried out a full pre surgery assessment which consisted of scalp measurements, medical history, medication, hair density and blood pressure. These early checks helped avoid delays or postponements on the day of surgery. If needed, people could meet the doctor before surgery. Doctors reviewed patient details electronically and fully assessed people on the day of surgery.

On surgery day, people had a full consultation with the doctor to review risks, plans and consent. Medical history was rechecked and re-signed. We observed a doctor preparing a patient, reviewing their health questionnaire, explaining the procedure and allowing time for questions.

A co-ordinator was available 24 hours a day post-surgery for any enquiries, and an on-call doctor was available for urgent out-of-hours queries. Follow up care was thorough and consisted of both phone, video and face to face follow up reviews. Staff stored discharge summaries electronically which were complete.

The service had an up-to-date safeguarding policy and a quick reference guide with contact details for the local authority and safeguarding lead. However, the policy didn’t reflect that many people who used the service came from outside the area and staff could benefit from using the NHS safeguarding app for wider support.

Safeguarding was part of the audit schedule, and no concerns were reported in the past year.

All staff completed role-specific safeguarding training of level 3 for adults and level 1 for children. This supported good awareness of risks, including those involving adults with children. However, not all staff were up to date with their training. Staff with expired training could not register for shifts, reducing any risk. We saw that managers actively followed up to ensure staff completed mandatory training. Policies were accessible in the staff room and staff were able to identify safeguarding concerns and how they would respond.

People who used the service told us that staff clearly explained the risks of their procedures. We observed thorough pre-operative risk assessments and confirmed physical checks were completed before, during and after surgery.

Staff completed a health questionnaire before and on the day of surgery, but it did not include specific mental health screening. Managers said they identified mental health concerns by reviewing people's medical history and medication.

People who used the service received written aftercare guidance and 24-hour contact details. Follow-ups were scheduled at 2, 7 and 14 days, 6 weeks, and 3 months, with face-to-face reviews at 6, 12 and 18 months. Staff sent text reminders and carried out detailed pre- and post-surgery checks to monitor progress.

Post-operative reviews included infection checks and hair transplant progress. Staff encouraged face-to-face appointments for visual and microscopic hair examinations. However, 43% of people missed their 12-month reviews. Managers told us that many people who used the service were satisfied and didn’t feel the need to return but were aware they could contact the service at any time after surgery.

We observed a doctor explain some potential risks including anaesthetic and infection risks. Doctors told us how local anaesthesia was given slowly to reduce discomfort. Staff asked people to rate pain from 1 to 10 after surgery. Audits showed 86% rated pain management as very good, 12% good, and 2% satisfactory.

We also observed a doctor giving aftercare advice, including return-to-work plans and transport home. People were reminded they could stop surgery at any time and were given time to ask questions.

Risk assessments were completed on arrival and reviewed during procedures. Staff checked blood pressure and doctors reviewed consultation notes and medical history. Where risks were identified, people were seen ahead of surgery to plan safe treatment.

All clinic rooms were clean, tidy and well maintained. During our visit, a sink in the assessment room was out of order due to a leak the night before. The issue was logged with the building provider, a sign was displayed, and hand gel was provided. The sink was repaired during the inspection. This showed the service dealt with environmental issues effectively.

Theatres had air conditioning and daily use of air purifiers.

Fire safety was well managed. Staff completed fire safety training, and fire wardens had specific training. The building provider carried out fire risk assessments, extinguisher servicing, PAT testing, alarm checks and emergency lighting inspections which were all completed in 2025. Weekly fire safety tests and audits were logged, and the evacuation plan was clearly displayed.

The service received safety alerts, discussed them in governance meetings and shared them with staff. Daily theatre environment audits were completed and reviewed, with clear actions taken when standards were not met.

The service had emergency procedures and equipment. Staff had access to a defibrillator, first aid kits, EpiPens, glucagon (stored in the fridge), and oxygen. A stretcher was available due to the lack of a lift. No emergency 999 transfers occurred in the past year.

Staff were trained in basic life support (BLS) and knew how to respond to emergencies. A quick reference flowchart was available.

Clinical waste was disposed of safely. Sharps bins were correctly labelled with signatures and dates, meeting Health and Safety regulations. People who used the service said the environment was clean and staff wore personal protective equipment (PPE).

On the day of our visit, 5 hair technicians assisted the doctor with a FUT procedure. We met the office manager, who was based at head office but carried out face-to-face assessments for the service. The registered manager, office manager, and senior technician were the only substantive staff. Doctors worked under practising privileges, and technicians were self-employed with abridged privileges.

Electronic staff records listed 51 staff, but only 7 technicians were active. Inactive staff remained on file for audit purposes. New staff were often referred to the service by colleagues.

Doctors received annual appraisals. Staff told us they received an anonymous survey every three months, inviting feedback on each doctor and suggestions for improvement. The doctors were not on the specialist register but were experienced at carrying out hair transplants and were members of the International Society of Hair Restoration Surgery (ISHRS). Several staff planned to attend the ISHRS conference in Berlin this year.

Mandatory training was delivered via an online platform, with progress monitored by the registered manager. Some staff completed their training through other providers they also worked for, and certificates were cross-referenced. On the day of our inspection, 2 staff had not completed all of their mandatory training, and the manager told us that staff were not permitted to work until they were fully compliant.

All staff had a full induction and training package. Mandatory training was then completed yearly. However, the service did not include learning disability and autism in their mandatory training. Following our inspection, the service added training on learning disability and autism, anaphylaxis, and freedom to speak up. We saw a new policy was introduced to support this and staff had been informed of this change.

Training records were reviewed quarterly, and compliance was reported at governance meetings. Staff who failed to complete training were removed from clinical duties.

Recruitment checks were not always complete. The recruitment policy stated that two professional references should be obtained, where we saw that not all staff had two professional references. The policy stated health checks to be carried out, which the manager told us meant to check staff had antibodies for hepatitis b. Not all staff had this check completed. The policy stated that a DBS or local equivalent should be obtained. This was unclear with some staff having enhanced DBS and some standard. The policy did not state how often these should be renewed and we saw that several DBS checks were over 10 years old and were used from previous employments. The recruitment policy lacked clarity. However, all staff received a full induction before providing care. Following our inspection the service told us they had now registered all staff on a live DBS register and all staff had an enhanced DBS.

No staff had received an appraisal, although these were scheduled for October 2025. Managers said staff were informally monitored during each shift, but formal annual appraisals were not in place. While most staff were self-employed, managers confirmed that following the inspection, all staff would be scheduled for appraisals.

Staffing levels were adequate. A mobile app was used to share shift updates and other communications.

The provider promoted a culture of peer review between technicians and doctors to support professional development.

We identified some infection prevention and control (IPC) concerns. Treatment rooms had only one sink each, designated for handwashing. This meant the service did not have sinks in the treatment rooms for cleaning equipment and therefore had these transported to the sterilisation room in sterilised solution filled lidded boxes. Staff were instructed not to clean equipment in these sinks, but during our inspection we observed petri dishes had been placed in a handwashing sink. The registered manager was informed, and she immediately actioned this by ensuring staff were reminded of correct procedures and recorded this as an incident. The sterilisation room’s handwashing sink was used for cleaning instruments, resulting in staff having to use a bathroom across the corridor for handwashing. The service had not completed a risk assessment to ensure risks of only having one sink in each room were mitigated.

Non-disposable surgical instruments including sapphire blades were sterilised using a benchtop steriliser. This was not in line with HTM 01-01 standards for critical devices as benchtop sterilisers are not validated for the sterilisation of critical equipment. The manager told us they used additional cleaning methods by using an ultrasonic bath for equipment prior to full sterilisation. We observed the service had carried out daily sterilisation tests and logs were maintained. Printouts were attached to diary pages for traceability. All instruments were single-use except FUT equipment, though single-use options were available if required. Following our inspection, the service informed us that they have now changed to single-use sapphire blades to align with HTM 01-01 standards. We reviewed autoclave training records for the senior technician, which was thorough and covered sterilisation principles, equipment use, monitoring, safety, and troubleshooting. Following our inspection the service told us that all instruments are now single use, including FUT equipment and the autoclave contract has been terminated.

We observed hand hygiene audits and these focused on doctors and excluded technicians, posing a risk as not all staff were monitored. The provider expanded their audit scope after our inspection to include technicians.

Staff used antibacterial wipes for small spills and spillage kits for larger blood spills. However, the staff handbook instructed cleaning small blood spots with paper towels soaked in freshly prepared hypochlorite solution (10,000 ppm or 1% chlorine) and did not mention disinfectant wipes. This created unclear guidance. Following our inspection the service told us that the staff handbook had been revised to include the use of disinfectant wipes.

In the past 12 months, the service reported two surgical site infections, both following follicular unit transplant (FUT) procedures. No infections occurred after follicular unit extraction (FUE) procedures. We saw individuals were treated successfully, and no patterns or concerns were identified. People received aftercare kits with cleaning supplies and clear instructions. Staff used personal protective equipment (PPE) properly, and all rooms were clean and clinical. After cleaning, rooms were inspected, and checklists and photos were uploaded to a secure portal to confirm thorough cleaning. Managers and doctors held quarterly meetings to review infection prevention and control audits and actions. We saw regular audits were monitored and learning actioned.

The service had a medicines policy in place and medicines were stored securely in a locked cupboard, accessible only to the registered manager and senior technician. All medicines checked were in date, and fridge-stored items like glucagon had up-to-date fridge temperature logs. We observed the control of substances hazardous to health (COSHH) cupboard was locked and clearly labelled.

The registered manager oversaw medicines management, including audits and signing medicines in and out for surgery. The manager had completed medicines training, and the senior technician was undergoing training. Doctors administered medications such as anaesthetics, antibiotics, and painkillers, which were signed out in individual service users’ names and recorded in medical notes with a signed prescription.

The service carried out thorough audits. We reviewed the July audit which had found missing anaesthetic batch numbers in three patient records, with actions put in place to reduce this and further refresher training for clinicians.

Medication use was monitored, with records of dosage, batch numbers, and expiry dates. The service did not have formal guidelines for disposing of expired medicines; the policy stated that expired or unused medicines must be disposed of in line with clinical waste regulations yet the manager told us that they had not had any expired medication and not had to deal with this, but should this happen, they would be diluted and flushed away. This process would breach the UK Environmental Protection Act and Hazardous Waste Regulations. The registered manager informed us following our inspection that the medicines policy now included expired medicines management and processes had now been put in place with a local pharmacy for returns. Sharps were disposed of correctly in approved containers.