Edgbaston Wellness and MediSpa

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

This key question has been rated as requires improvement. The service was in breach of legal regulation in relation to safe care and treatment. We assessed all quality statements in the safe key question.

This service scored 47 (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 systems to record and investigate complaints and processes for staff to report incidents and safety events.

However, the service had failed to identify learning incidents and safety events, such as equipment and medicines that were missing or out of date and failings in the security of controlled drugs. Immediate action was taken during our assessment process to ensure the security of controlled drugs. The provider implemented a security and authorised access policy which was shared following our assessment. The provider also took immediate action to dispose of all out of date stock items and ensured all required emergency medicines were available.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider had systems in place to share important or urgent information with NHS services when required. We saw that patients’ GPs had been informed of treatment where appropriate.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. There was a safeguarding lead. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Data Barring Service (DBS) checks on staff were in place where needed and were reviewed annually.

However, we found that recent safeguarding concerns had not been assessed appropriately. This has since been actioned by the provider.

The service worked with patients and together as a clinical team to understand and manage risks by thinking holistically about patients. Patients were given advice on risks related to their condition.

The service had not detected and controlled some potential risks in the care environment. During our assessment on 12 November 2025, we saw that a defibrillator was in place, however, defibrillator pads were out of date. The provider took immediate action to replace these. During our visit on 17 November 2025, we saw these had been replaced. Records were provided following our assessment to demonstrate the defibrillator had been calibrated.

At our visit on 12 November 2025, we found several pieces of equipment that could be used during minor surgical procedures were out of date and therefore unsafe for use. This included a catheter, needles, forceps, histology sample beakers, finger prick blood sugar test strips, a child mask and connecting tube, and liquids used for prepping hands and patients for surgical procedures. The provider took action to dispose of all out-of-date equipment and put processes in place for more robust system for stock checks.We did not find evidence that this equipment had been used or that harm had been caused to patients. During our visit on 17 November 2025, we saw these actions had been carried out. However, these issues should have been identified and addressed through the provider’s own internal quality systems and checks.

Contracts were in place through the landlord to ensure the premises were maintained safely and appropriately. There was a business continuity plan in place which was monitored and reviewed.

The service employed a range of clinical and non-clinical staff. There was a specialist consultant urologist, general practitioner (GP), nurse, and two healthcare assistants. There was a clinic manager and three reception staff.

However, checks were not always kept at the service for all staff recruited. Some staff had been recruited from an NHS GP practice and recruitment records could not be provided for the inspection. The provider said these had been kept on paper at the other service. Therefore, there was no assurance that the service had completed the appropriate recruitment checks for these staff. We saw that moving forward there was a new process for ensuring recruitment checks were robust and kept electronically so that they were accessible.

Training records were not always up to date, and it was not always clear if staff had completed mandatory training. For example, the provider told us two staff had completed chaperone training but could not provide the certificates or training log to confirm this. Other staff did have a chaperone training certificate. Following our assessment, we were provided with evidence that formal chaperone training had taken place and that these staff members had signed a ‘chaperone self-certification of completeness and essential knowledge’ document. The service had plans to keep an up-to-date electronic training log but this was in progress.

We saw that appraisals were completed with staff.

The provider did not always ensure that infection prevention and control measures were in place. During our site visit on 12 November 2025, we saw the room used for minor surgical procedures was not fit for purpose and did not meet the required infection prevention and control standards. This increased the risk of postoperative complications from infection. The tap was a standard tap and not able to be turned on and off easily using elbows following prepping for procedures. The flooring was not coved and instead had skirting boards around the room which did not allow for thorough cleaning to prevent infections. The walls were not wipeable. The cupboard below the sink was stocked with equipment. The room was cluttered with equipment stored on the floor.

Following this visit the provider took action to rectify the issues. We saw at our visit on 10 December 2025 that the sink, tap, flooring, walls and clutter had been addressed.

However, there was an infection prevention and control (IPC) lead and policy in place. Staff had completed infection control training. The provider had put in new processes for regular audits of the clinic room by the management, but this was still in the early stages of being implemented.

The service did not always ensure that medicines were safely managed.

During the site visit on 12 November 2025, we identified that essential emergency drugs were unavailable, compromising the ability to respond effectively to urgent medical situations. There was no system for what medicines were needed in the case of an emergency. There was no risk assessment for emergency medicines not held on site. Some emergency medicines were out of date so had unknown risks for service users. Emergency medicines were not kept together with a clear list for quick identification in an emergency. Following our visit, the provider took action to address the issues, pausing regulated activities until essential emergency medicines were in place. At our visit on 17 November 2025, we saw that the service had emergency medicines in place, accessible to staff, with lists of those available.The provider introduced an improved system to monitor medication stock and provided supporting evidence following our assessment process.

At the site visit on 12 November 2025, we saw the controlled drugs cupboard was not locked and the room where these were stored was unlocked. Patients had access to this room causing a risk of patients accessing controlled drugs. Following this visit, the provider took action to implement a process for keeping the clinical room and controlled drugs cupboard locked. We saw at our visit on 17 November 2025 there were clearer protocols for when the allocated staff could access the controlled drugs cupboard.