London PMS and Menopause 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 looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC in February 2021 under this provider. This key question has been rated as Good. This is because we found no concerns with patient care and safety.

This service scored 66 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding.

The service encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints. Learning from incidents resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The service provided treatments to adults only. Patients’ identities were verified verbally. However, after the assessment, the service reviewed their policy and is going to ask for photo ID at the time of registration.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had a documented policy in place regarding emergency medicines and equipment. While an oxygen cylinder and a defibrillator were not stored directly on-site, the service had an arrangement in place with the clinic downstairs, which had a portable defibrillator machine (AED) and oxygen. It was agreed that the service could use these when necessary, with access available during all clinic times and a retrieval time of around one minute. The team had been made aware of where this equipment was located. On the day of the assessment, we found that the atropine was not in stock, but this was ordered immediately.

Staff were suitably trained in emergency procedures. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The service gave patients after-care information once treatment had been given and ensured the patient knew who to contact if there were any concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were contracts in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

Fire safety control measures were in place and regular checks had been completed. A formal documented fire risk assessment was carried out on 24 September 2025 by an external contractor. The contractor was carrying out routine fire safety checks to maintain fire safety at the premises. The internal fire risk assessment was carried out in July 2025. The fire system and fire extinguishers were inspected regularly; with comprehensive records maintained for all fire alarm checks. The service carried out regular fire drills. Fire safety training had been completed.

Portable appliance testing was carried out on 19 March 2026.

Calibration of medical equipment was not required, as the service decided to replace basic medical equipment annually.

During the assessment, we noted that the DEXA machine (a specialised type of low dose x-ray scanner) was regularly checked and calibrated to ensure accurate bone density measurements.

A gas safety check was carried out on 22 September 2025.

The Electrical Installation Condition report (EICR) of the premises had been carried out on 13 May 2026.

The Legionella risk assessment was carried out on 17 October 2025. However, records of water temperature monitoring and water flushing were not available on the day of the assessment, so the service was unable to demonstrate effective oversight of this risk.

There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the service. We found the training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

We reviewed 2 staff files and found most recruitment checks were carried out in accordance with regulatory requirements. All staff had received Disclosure and Barring Service (DBS) checks appropriate to their role except the practice manager, who had a basic level check. However, the service informed us that an enhanced DBS application was submitted after the assessment. In addition, the service informed us that the practice manager previously held an enhanced DBS check, but it was not kept in the staff file.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The environment was noted to be clean and tidy during our onsite visit, and all appropriate personal protective equipment was available for staff to use.

Feedback from people who use the service, was positive in relation to the cleanliness of the environment.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

We reviewed 10 clinical records, which were completed appropriately and stored electronically on a secure network. Records were complete, accurate and up to date. Consultation notes demonstrated appropriate clinical decision-making. Staff followed established prescribing protocols and ensured medicines were prescribed safely. People knew what to do and who to contact if they experienced any unexpected symptoms.

There was no medical fridge in the premises.

The service had effective systems to manage and respond to safety alerts and medicine recalls. Safety alerts were received by a dedicated person and managed effectively.