The Pemberdeen Laser Cosmetic Surgery Clinic Limited

Updated 21 April 2022

The Pemberdeen Laser Cosmetic Surgery Clinic Limited is registered with the Care Quality Commission to provide the regulated activity of surgery.

This private hospital opened in 1985 and was registered to provide the regulated activity under a different location name. The hospital is situated in south east London. The hospital primarily serves the communities of the London and north Kent areas but also accepts patient referrals from the wider community.

The hospital carries out the following regulated activity: Surgical Procedures. The hospital provides a range of cosmetic surgery, including liposuction and abdominoplasty. Over 95% of procedures were for breast augmentation. The service offers cosmetic procedures such as dermal fillers. We did not inspect these services, as they do not come under the requirements of current regulations.

Except for the nominated individual, who is the hospital manager, all staff are employed on a temporary basis. This means the workforce is transient and works on a temporary basis under agency or locum agreements.

We have inspected the hospital location 19 times since its registration and under the former location name. The most recent inspection was in July 2021, during which we rated the provider inadequate overall and inadequate in safe, effective, and well-led.

We had previously suspended the provider’s registration to provide surgery services due to concerns about safety and governance. At the time of this inspection, the provider had resumed these services under certain conditions. There was no registered manager in place. The nominated individual, who was also the hospital manager, told us in July 2021 that they planned to undergo the registered manager process. This had not been completed by December 2021. Their initial application had been rejected because of an error in the information submitted. The registration procedure was still in progress at the time of inspection.

We saw on this inspection the service had made improvements and we rated the provider as requires improvement overall and requires improvement for safe, effective, responsive and well led. Caring remained good.

Updated 21 April 2022

Following the lifting of restrictions on the regulated activity of surgery at this hospital location, we continued to have concerns about governance, risk management, and the ability of the provider to maintain the service. However, the new hospital manager had initiated improved practices. These were in the early stages and required significant development but indicated the provider’s willingness to progress.

Our rating of this service improved. We rated it as requires improvement because:

• The service’s clinical care and support functions were fulfilled by a transient, temporary workforce working under a range of different agreements. Staffing levels were arranged to meet patient’s needs.
• Systems to maintain practising privileges for surgeons and consultants had improved.
• Appraisals provided no consistent assurance of competence, abilities or staff development.
• The service used equipment and control measures to protect patients, themselves and others from infection. The premises were visibly clean. However, a recent infection control audit had highlighted areas where infection control practice could be improved.
• Staff kept detailed records of patients’ care and treatment. However, there was room for improvement in the consistency of risk assessments and monitoring. We were also not assured staff recorded all cosmetic implants on the clinic implant register.
• The service investigated incidents but there was limited evidence of learning being shared with staff.
• There was limited evidence of the service’s ability to adapt to individual needs. There were no arrangements for language support and no practical application of guidance to ensure cultural or religious needs were met.
• The service manager had introduced effective governance processes that were adequate for the current levels of surgical activity. A senior management team (SMT) had been assembled to overview the processes and procedures at the clinic.
• Patients generally spoke positively about their experiences of care and treatment.

While there was still significant room for improvement, the hospital manager had implemented a range of new measures to return the service to compliance.

Updated 21 April 2022

See overall service summary.