Signature Clinic - Manchester Also known as Rochdale Clinic

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

Our rating of safe stayed the same. We rated safe as requires improvement.

We identified regulatory breaches relating to infection, prevention and control processes in the key question for safe, where we have told the service it needs to make improvements.

We found the service did not have effective systems to identify or prevent surgical site infections. The service also used benchtop sterilisers to decontaminate reusable surgical instruments on site, which was not in line with current national guidelines.

However, we also found areas of good practice.

The service had enough staff to care for people and keep them safe. Staff had training in key skills, understood how to protect people from abuse and managed safety incidents and medicines well. Premises and equipment were clean and well-maintained.

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.

People who use the service told us they felt safe and did not have any concerns around safety incidents. They understood how to raise any concerns with staff.

Staff knew what incidents to report and how to report them. All the staff we spoke with had access the provider’s electronic incident reporting system. Staff understood their responsibilities regarding duty of candour legislation.

Staff told us any reported incidents were discussed at daily huddles and during monthly clinical governance meetings so shared learning could take place. Staff also told us they received regular safety bulletins and newsletters relating to lessons learned from incidents to aid their learning.

We identified concerns around incident reporting and learning from incidents during our previous inspection in January 2024. During this inspection we found improvements had been made.

The service had implemented an electronic incident reporting system in June 2024. Staff identified, reported and managed reported incidents in line with the provider’s incident reporting policy.

Incidents were investigated by senior staff with the appropriate level of training. Incident records were completed appropriately and remedial actions were put in place to aid learning and improvement.

There had been no patient deaths, never events or serious incidents reported by the service during the past 12 months.

There was an improved culture around safety and learning. Staff understood the duty of candour.

Staff received feedback following the investigation of incidents. Staff met to discuss the feedback and look at improvements to people’s care during daily safety huddles and monthly clinical governance and compliance staff meetings.

People who used the service told us they had an initial consultation to assess their needs and preferences and to determine if they were eligible for surgery. They told us information about their planned surgery was clearly provided and explained to them.

People told us they were they were monitored by staff during their procedure. They told us they received information about post-operative recovery and the aftercare service as part of the discharge process.

Staff told us people had a consultation prior to surgery to determine if they were suitable for surgery and to identify their needs and preferences. They were able to describe the provider’s inclusion criteria and understood the provider’s policies for admission, discharge and transfer of people who used the service.

Staff told us they used an electronic bookings system to manage people’s appointments and post-operative follow up appointments. They told us they used paper based care records and surgical pathways to document people’s care and treatment and these were scanned electronically following completion.

Staff understood the process for managing patients during an emergency. They told us they carried out routine observations during surgery and people with deteriorating health would be stabilised and transferred to the local NHS hospital if they required emergency treatment.

The bookings team and consulting doctors were based at one of the provider’s other locations. The consulting doctors told us the bookings team scheduled an initial on-line consultation following initial enquiries from people interested in some low risk cosmetic procedures at the clinic.

They told us they discussed treatment options, medical history and assessed people’s eligibility for treatment against the provider’s inclusion criteria. People who agreed to progress with surgery were given further information, including explanation of fees, consent processes and obtaining images to enable further review by the surgeons.

The aftercare team manager told us people who used the service were given information about the aftercare process and contact details for the team as part of the discharge process.

The provider’s booking team gave people initial information about the services offered and arranged a pre-operative consultation.

People undertaking medium or high risk procedures, such as fat removal, had their initial consultation with the operating surgeon. People undergoing minor low risk procedures, such as blepharoplasty (eye lid surgery) had their initial consultation remotely by a team of consulting doctors based at another location. A further consultation with the operating surgeon could be arranged, if required.

The service’s inclusion criteria meant certain people were not eligible for treatment at the clinic, such as people with complex health conditions and those unable to consent to treatment. People admitted for surgery were generally fit and healthy.

Staff liaised with people’s general practitioner (GP) if there were any queries around a person’s health status or if any test results were required, prior to admitting people for surgery.

All clinical and support staff had completed life support training. Staff followed the provider’s recognition and transfer policy for managing people whose health deteriorated during surgery. There had been no instances where in the past 12 months where a person required emergency transfer to hospital.

Care record audits were undertaken every 8 weeks. Recent audit records showed good levels of staff compliance. Care records we looked at were complete and up to date, with few errors or omissions.

There had been 2,238 cosmetic surgical procedures undertaken at the clinic during the past 12 months, with between 158 and 232 procedures taking place each month during this period. There had been 17 readmissions for revision surgery during this period.

The service had an admissions and discharge policy. Staff completed discharge checklists and provided verbal and written information to people following discharge from the clinic. Post-operative follow up appointments were managed by the aftercare team.

People who use the service told us they had not experienced any instances of abuse or neglect at the service. They told us if they had any safeguarding concerns, they would raise them with the managers.

Staff were aware of the provider’s safeguarding policy. They told us they had completed mandatory children and adults safeguarding training.

Staff understood how to make a safeguarding referral and who to inform if they had concerns. They knew how to access support from safeguarding leads.

Staff told us that learning from any reported safeguarding incidents was shared as part of daily huddles and during monthly clinical governance meetings.

The provider’s safeguarding policy instructed staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as the local authority safeguarding team.

The service had safeguarding leads and senior managers had completed the higher level of safeguarding training for children and adults.

All eligible staff had completed level 3 children and adults safeguarding training. The safeguarding training also included radicalisation (prevent), modern slavery and female genital mutilation (FGM) training. The training was in line with current intercollegiate guidance for adults and children.

The service had reported 1 safeguarding concern in the past 12 months. Appropriate actions had been taken to protect the vulnerable person, with involvement from local mental health and social services teams.

Meeting minutes showed safeguarding incidents were routinely discussed at monthly clinical governance and performance meetings and provider-level safeguarding leads meetings that took place every 3 months.

People who used the service told us staff assessed key risks around their procedure and discussed these with them before undergoing surgery.

People told us staff carried out routine observations before, during and after their procedure and kept them informed about any changes to their care or treatment.

Staff understood how to identify and manage risks. They told us risks to people were discussed during initial consultations and risk assessments were carried out on the day of surgery to determine people were suitable for surgery.

Staff told us new or emerging safety risks were discussed during daily safety huddles.

Staff were able to describe how they monitored people’s care and treatment, including undertaking vital observations. They understood how to identify and manage people with suspected sepsis or those whose health condition deteriorated.

People underwent a medical consultation prior to undergoing surgery to identify key risks and to determine their eligibility for surgery. Staff took action to mitigate identified risks, where possible. For example, people identified with latex allergies or those with an infection history were scheduled at the beginning or end of theatre lists.

People who used the service were assessed by the surgeon on the day of surgery to identify any changes to their medical condition and whether treatment could commence.

Care records showed staff completed risk assessments for each person on admission to the clinic, such as for venous thromboembolism (VTE – blood clots) and infection history risks.

Staff held daily safety huddles and briefs where key risks were reviewed and discussed.

Staff used the national early warning score (NEWS2) and carried out vital observations before, during and after surgery to ensure any changes to people’s medical condition could be promptly identified and escalated. Care records showed staff completed timely observations and identified and escalated any issues or risks appropriately.

We observed two theatre teams undertaking the ‘five steps to safer surgery’ procedures, including the use of the World Health Organization (WHO) checklist. The theatre staff completed safety checks before, during and after surgery in line with WHO guidelines. Care records showed surgical safety checklists were completed correctly.

Managers carried out WHO safety checklist compliance audits and VTE risk assessment compliance audits every 2 months. Recent audits between May 2023 and November 2023 showed high levels of staff compliance (100%).

The sepsis management policy included guidance for staff around identifying and managing patients with sepsis, based on the sepsis six care bundle. There had been no instances where sepsis was suspected or identified in the past 12 months.

People who used the service told us the clinic was safe and provided a suitable environment for their care and treatment. They told us they had not experienced any issues relating to equipment and felt the premises and equipment was suitably maintained.

Staff told us the premises and equipment were suitable for providing safe care and treatment. They told us there were sufficient quantities of equipment and consumable items and they could easily access them when needed.

Staff told us they carried out routine monthly stock checks to check they had sufficient stock and to check consumables and single use sterile items were within expiry dates.

Staff told us there was a clear process for reporting any faults relating to the equipment or the premises. They told us any reported issues were promptly addressed by the maintenance and facilities staff.

All the areas we inspected were well-maintained, free from clutter and suitable for providing safe care and treatment.

Access to the clinic was secure with coded entry. The reception area was located on the ground floor and was spacious and suitably furnished. The service had sufficient numbers of toilets and change areas for staff and service users.

There was sufficient space for storage of equipment and consumables. Single use items and consumable were stored safely and were within expiry dates.

The service had enough suitable equipment to help them provide safe care and treatment. There were arrangements for the safe handling, storage and disposal of clinical waste, including sharps.

Flammable chemicals were risk assessed and safely stored, in line with control of substances hazardous to health (COSHH) guidelines.

Emergency resuscitation equipment and medicines were kept securely and log sheets showed these were checked daily.

All the clinical areas were located on the first floor and the service did not have a lift, which meant the clinical areas were not accessible by wheelchair. The associate director of clinical services told us patient’s mobility was assessed as part of their initial consultation and patients that could not use stairs or required wheelchair access were offered treatment at one of the provider’s other locations. Equipment maintenance and servicing was overseen by a biomedical engineer under a planned maintenance schedule. The service reported all portable appliance testing (PAT) and equipment service calibrations at the clinic were in date. The service reported there had not been any incidents relating to equipment during the past 12 months. The service had a formal business continuity plan that outlined the steps required by staff to manage key risks that could affect the provision of care and treatment, such as a power outage or shortage of staff. There were suitable arrangements in place for fire safety, including clear instructions for staff to follow in the event of a fire.

People who used the service told us there were enough staff in the clinic and they provided safe care and treatment. They spoke positively about the way staff communicated and interacted with them and told us staff were professional, friendly and responsive to their needs.

People told us they felt staff were suitably trained and competent in their roles and they did not have any concerns in relation to their competence and abilities when providing care and treatment.

Staff told us there were enough staff to provide safe care and treatment. They told us their workload was manageable and they received good support from managers.

Staff told us they kept up to date with mandatory training and were supported to complete training. Managers told us they monitored training compliance and informed staff when they needed to update their training.

Staff told us they received an induction and underwent competency based trained when they started their role. They told us they received annual appraisals.

Staff were positive about on-the-job learning and development opportunities and told us they were supported well by their managers. The clinic staff training day was received positively by clinic staff and managers planned to undertake further training days every 6 months to maintain staff training and support.

Managers told us the service had a vacant scrub nurse post that had recently been recruited to and pending commencement. A temporary agency nurse was used until the substantive nurse commenced employment. There were no other staff vacancies.

The clinical education and supervision manager was appointed in October 2024 to provide additional training and support for staff.

The 3 operating surgeons were registered with the general medical council (GMC) and registrations were up to date with no outstanding queries or revalidation issues. None of the surgeons were on the GMC specialty register. The medical director and director of clinical services told us the surgeons did not work in the NHS but were experienced and had undertaken significant numbers of procedures. They told us their performance was routinely monitored as part of their practicing privileges and no significant concerns had been identified through their most recent clinical appraisals.

We saw the service had enough medical, nursing and support staff to keep people safe. The operating surgeon was supported by an operating department practitioner, scrub nurse and a healthcare support worker. The clinic supervisor oversaw admissions on the day of surgery. A support worker was designated as a coordinator and two others were designated for sterilisation of surgical instruments.

The clinic manager oversaw the day to day running of the service. The clinic had 3 surgeons working under practicing privileges, an operating department practitioner, 5 healthcare support workers, a clinic supervisor and a part-time administrator.

The clinic staff were supported by an aftercare team consisting of 2 part-time and 2 full time staff and 5 consulting doctors who were based at another of the provider’s locations.

We observed staff interacting with patients and saw staff were friendly, calm and polite when communicating with patients and delivering care and treatment. We saw that patients calling for staff assistance and they responded promptly.

The service had enough medical, nursing and support staff to keep people safe. All procedures were scheduled in advance, enabling managers to plan and adjust staffing resources in advance according to people’s needs.

The theatres were suitably staffed in line with national guidelines, such as the association of perioperative practice (AfPP) guidelines for safer staffing.

Sickness and leave cover was provided by the existing staff. Agency staff usage was low. Staff sickness and turnover rates were low. Where bank or agency staff were used, managers made sure they had a full induction and understood the service.

Staff received and kept up-to-date with their mandatory training. Most staff had completed mandatory training and compliance was above provider’s training completion targets.

Staff received a full induction before they started work and had regular clinical competency checks. All clinic staff, including the surgeons, had completed annual appraisals within the past 12 months. The surgeons’ clinical appraisal was undertaken by an external designated responsible officer.

A clinic staff training day took place in July 2024. This included additional training around governance, incidents, clinical processes, infection control and medicines management processes.

The provider’s recruitment policy outlined the recruitment checks carried out for newly employed staff. We looked at records for 3 substantive and 1 agency staff files. They showed appropriate recruitment and pre-employment checks had been carried out.

The practicing privileges policy stated medical staff working under practicing privileges were periodically reviewed 3 years, with supporting documents submitted annually. Records for the 3 surgeons working at the clinic showed appropriate pre-employment checks had been carried out. The records included up to date training, indemnity and professional body registration records.

Staff processes were monitored during monthly governance meetings.

People who used the service told us the premises and equipment were visibly clean and tidy and they did not have any concerns relating to the cleanliness of the environment and equipment.

People told us staff used gloves and aprons when providing care and treatment. They told us staff washed their hands before making contact.

Staff told us they had completed mandatory training in infection prevention and control (IPC). They told us they could access the provider’s IPC policies and could contact the IPC nurse manager if they required any support or guidance. Staff were aware of the provider’s policies for infection prevention and control (IPC) and knew how access these. They told us they had completed mandatory IPC training. They told us they could contact the IPC nurse manager if they required any support or guidance. Staff understood the processes managing risks related to the infections. They were able to describe how they cleaned and decontaminated equipment. They understood when people required isolation and how this should be carried out. Staff told us managers undertook regular infection control and hand hygiene audits. Managers told us if there were any shortfalls in hand hygiene or infection control compliance then these would be discussed with individual staff members to improve compliance.The IPC manager told us they were responsible for infection control processes at the clinic and attended the clinic one day a month, attended routine meetings, undertook audits and provided support and training for staff. The service had updated the aftercare process so any reported post-operative surgical site infections would be reviewed by the IPC nurse manager. The IPC nurse manager told us they had developed an aftercare surgical site infections screening tool to improve identification of post-operative infections. Service managers stated wound swabs could be taken from patients presenting at the clinic with signs of post-operative infection. The IPC nurse manager also stated they planned to enable people to undertake wound swabs in their homes where suspected post operative site infections were reported in order to identify the specific infection type and enable more effective treatment through narrow-spectrum antimicrobials; however this process had not yet been implemented by the service.

The theatres area and supporting areas were visibly clean and had suitable furnishings that were clean and well-maintained.

Cleaning schedules and daily checklists were in place and up to date. Staff understood their responsibilities for cleaning the environment and cleaning and decontaminating equipment.

We observed staff preparing people who use the service prior to surgery and using aseptic non-touch technique appropriately. There were enough hand wash sinks and hand gels.

All the staff we observed wore suitable personal protective equipment while delivering care. We observed staff following hand hygiene and 'bare below the elbow' guidance appropriately.

The service used a benchtop autoclave to sterilise reusable surgical instruments on site. Sterilisation was carried out by two trained healthcare assistants who had completed additional competency-based training. We saw there was appropriate segregation of clean and dirty instruments with clean to dirty flow in the decontamination room.

Colour-coded boxes were used for transfer of dirty and clean instruments. Sterile instruments were stored in sealed pouches with clear expiry dates. There was a tracking and traceability process in place to enable staff to identify if any equipment that had not been effectively sterilised.

We saw evidence to show staff used validated sterilisation cycles and the sterilisation equipment was routinely maintained and serviced by an external contractor.

Equipment logs showed staff carried out Helix (steam penetration) tests, air leakage tests and automated control tests daily before use of the equipment and weekly residual protein tests.

The service used benchtop sterilisers for decontaminating surgical instruments on site. Whilst processes and checks were in place to reduce risks, the use of benchtop autoclaves was not in line with the Health Technical Memorandum 01-01 (2016) guidance which states ‘Where benchtop sterilisers are still available, these should be a last resort’. The service planned to transfer instrument sterilisation to an external sterilisation provider. The clinic reported 47 post-operative surgical site infections during the past 12 months (equivalent to 2.1% of all procedures). Staff took actions to treat individual site infections, such as surgeon reviews and additional antimicrobial prescribing and monitoring to check the treatment had been effective. However, the service did not have effective systems to identify or prevent surgical site infections. The service recently introduced IPC nurse manager oversight for any reported post-operative surgical site infections. The service also planned to introduce wound swabs for each reported post-operative site infection in order to identify the type of infection and enable more effective treatment through narrow-spectrum antimicrobials; however this had not yet been implemented by the service. IPC committee and governance meeting minutes showed post-op infection rates were reviewed and treatments for individual service users’ infections were undertaken in isolation. However, we saw limited evidence to show managers had undertaken holistic, detailed investigations to identify the cause(s) of surgical site infections or to prevent or minimise the risk of reoccurrence. The service had infection control policies and staff completed mandatory infection control training. Hand hygiene and IPC audits took place every 3 months. Recent audits showed high levels of staff compliance for IPC audits (94%) and hand hygiene audits (100%). Action plans were in place and these were followed up to improve compliance.

People told us staff gave them clear information around medicines and their medicines were prescribed and administered appropriately, including to take home medicines following discharge from the clinic.

People told us they received medicines in a timely manner and did not have any concerns around the storage and handling of medicines.

Staff told us they received training in medicines management and were aware of how to access medicines management policies and procedures. They told us they could seek advice and guidance from the group pharmacist if they had any concerns around medicines management.

The group pharmacist was based at another location and told us they attended the clinic on a monthly basis, carried out medicines management audits, supported staff training and provided support and guidance for staff.

Staff told us people with their own medicines routinely self-administered their own medicines. They gave examples of how they supported people, such as those with diabetes, with administering their medicine whilst at the clinic.

Staff told us they could occasionally prescribe a low dose pre-med sedative for people with anxiety to help them relax before undergoing surgery.

Where this was agreed, people were assessed for suitability prior to undergoing surgery and allowed additional time for recovery before being discharged. The sedative was prescribed by the consulting surgeon for a person to collect from a local pharmacy and bring to the clinic on the day of their surgery. They would then be consented and reviewed by the surgeon prior administering the sedative and documenting in the care record.

Medicines were stored securely in a room in the theatre area, which had secured access.

We looked at a sample of medicines and found these were stored securely, reconciled correctly with stock records and were kept within their expiry dates. The service did have store any controlled drugs on site.

Medicines that required storage in fridges had been stored appropriately. Fridge and room temperatures were monitored daily to check the temperature was correct.

Emergency oxygen cylinders were stored securely and routinely checked and replenished. Emergency medicines were checked on a daily basis and kept within expiry dates.

People’s existing medicines and medical history was reviewed as part of the pre-operative consultation to determine if they were suitable for surgery. People taking certain medicines, such as anticoagulants (blood thinners), were given specific instructions on how to temporarily stop taking these medicines prior to undergoing surgery to reduce the risk any complications.

There was an arrangement with an external pharmacy provider for the supply and return of medicines used by the clinic. Staff maintained up to date records for ordering medicines. Clinic staff carried out routine checks to maintain medicine stocks. This included checking stock reconciliation and expiry dates.

The service reported one incident relating to medicines management. This related to a dispensing error that had not resulted in any patient harm.

Medicines management audits took place every 6 months. Recent audit records showed high levels of staff compliance (95%). Actions plans were taken to improve any shortfalls identified and were followed up to check improvements had been made.

All medicines administered by staff at the clinic and to take home following discharge were prescribed by medical staff. Staff used private prescriptions that were kept securely with controlled access. The service used an e-prescription service from an external provider that enabled people to collect their prescription from local pharmacies near their home.

People’s medicines were appropriately prescribed, supplied and administered in line with the relevant legislation and best practice guidance. Staff completed medicines records accurately and kept them up-to-date. We looked at 5 medicine administration records and they were complete and up to date, with few errors or omissions.