The Fertility & Gynaecology Academy

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• 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: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. This means we looked for evidence that people were protected from abuse and avoidable harm.

The last assessment of this service on 16 January 2014 was under an old methodology and was not rated. This is the first time this service had been rated. We have rated safe as requires improvement.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service did not always have 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 learned but we were not assured they were always shared with staff to embed good practice.

Not all staff understood the term duty of candour; staff mandatory training did not include duty of candour training. Staff told us they would be open and honest with patients if things went wrong but they did not know if there was an official process to follow. This meant duty of candour might not always be applied in line with legislation and patients might not be told if something had gone wrong. We requested to see the duty of candour policy, but this was not provided therefore there was no evidence the clinic had a policy for staff to follow.

All staff knew what incidents to report and how to report them. We spoke with 4 members of nursing staff who told us they could complete and incident form and submit this to their manager. Staff knew how to access this form. Feedback from complaints and incidents was given at staff meetings. We requested the minutes of staff meetings, but none were provided and therefore we were not assured learning was shared and staff who were unable to attend the meeting could review the minutes.

The service reported zero serious incidents for activity regulated by the CQC over the last 12 months. There had been incidents regarding activity not regulated by the CQC and staff told us about these. We spoke with the quality manager who told us the last incident concerned activity not regulated by the CQC. They described what had happened and what action had been taken. As this concerned equipment failure unrelated to patient care, duty of candour was not applied.

We reviewed a non-conformation reporting form and found that the incident was reviewed, learning identified and the action to take documented. This was shared across departments as all staff were responsible for learning what action to take, however we could not corroborate this by reviewing the minutes of staff meetings as these were provided during or following our inspection.

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.

Nursing staff, healthcare assistants and consultants worked well together and there were good working relationships between clinical and non-clinical staff. As the team was small, staff undertook several roles meaning all staff worked together throughout the day. We observed staff working well together.

Patients self-referred to the clinic, and self-funded their treatment. Patients received a comprehensive assessment during their initial appointment with the service. A medical history was taken and allergies recorded. Additional needs were recorded in the patient records we reviewed, although staff we spoke with were unable to recall a patient they had treated with additional needs. Risk assessments were carried out to assess patients’ suitability for treatment and further assessments were carried out depending on the treatment plan. Patients undergoing activity not regulated by the CQC were assessed by anaesthesiologist to ensure they were risk assessed before any procedure commenced.

Where necessary, patients could be referred to other services for treatment with another prover and maternity care. Once patients had received their treatment, they self-referred into another care provider or the NHS to continue with maternity care. With the patients consent, a letter of referral or summary of treatment could be provided and sent via an encrypted email to another provider to ensure continuity of care.

With the patient’s consent, a discharge summary was sent to the patient’s general practitioner (GP). Patients were given a copy of their discharge summary and images from scans.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Not all staff had received safeguarding training and not all staff we spoke with knew safeguarding was part of the mandatory training programme. In staff files we reviewed, 4 of the 6 employees did not have documented evidence of safeguarding training being completed. The 2 members of staff who had received training had completed safeguarding training for adults and children to level 2 and this was now out of date. The training certificate was valid for 12 months and was over 2 years old at the time of the inspection. Staff and leaders were not clear when the renewal date for training was and could not tell us when training was due. We reviewed the safeguarding adults standard operating procedure (SOP) and found that it did not state the level of safeguarding training that staff needed to complete and the frequency this should be renewed. It did not reference what level of training was required to different roles at the clinic. For example, it was not clear if healthcare assistants, nurses and medical staff required the same level of training and whether training above level 2 had been considered. The safeguarding lead was the registered manager who had completed safeguarding training to level 2 which was not in line with national guidance. We were not assured staff had received the training necessary for their role to help keep patients safe from abuse. This meant staff might not be appropriately trained in line with national guidance putting patients’ safety at risk.

Not all staff understood the relevance of topics within safeguarding such as female genital mutilation (FGM) or domestic violence. This meant patients might not be appropriately identified as being at risk or action taken to keep them safe.

We spoke with 2 registered nurses and 2 healthcare assistants, not all of whom had not received safeguarding training at the service; however, they understood the importance of safeguarding from previous experience and had a good understanding of the risks. They gave a good description of different safeguarding concerns relevant to the patients they saw and knew what to look out for and how to report concerns.

The safeguarding SOP listed points of contact for the local authority in order to refer a patient if necessary. Staff we spoke with told us they would escalate concerns to senior leaders and were not aware of the contacts details available.

In the last 12 months the service had not made any safeguarding referrals. Therefore, we were unable to confirm if risks had been identified and acted on to safeguard patients.

The service worked with people to understand and manage risks by providing care in a way that was safe and supportive and enabled them to do the things that matter to them.

Staff told us they discussed the risks of treatment and procedures with patients at their initial appointment in the clinic. These risks were mentioned again when obtaining patients' consent throughout the treatment. They said patients were offered the chance to ask questions or raise concerns at all stages of their treatment. Patients we spoke with told us they were able to ask questions and were able to discuss different treatment options available. Patients told us the procedures were well explained, and the risks and benefits were discussed. There was no pressure to decide upon a treatment plan during the appointment, and they were given time to make an informed decision.

Staff enabled patients to give feedback on the service they received, either in person or through the patient survey. We reviewed the patient satisfaction feedback audit and found that 14 forms had been reviewed as part of the audit, it was not clear how many feedback forms had been collected in total. There were no dates on the audit, so it was unclear what time period the feedback related to, the feedback audit was dated September 2025. The questions in the feedback related to the care patients had received while in the clinic, there were no negative indicators in the responses with 12 out of 14 responses indicating patients were very satisfied with treatment options available. However, as it was unclear what percentage of patients using the clinic this sample related to, how the sample had been selected and the time period the feedback was given over, we could not be assured this feedback was representative of patients using the service.

The service had a chaperone policy, and all patients could request a chaperone. The policy stated that a chaperone would be offered to all patients undergoing an intimate examination. Patients we spoke with told us they had been offered a chaperone and staff we spoke with had a good understanding of how vulnerable patients might feel and therefore request a chaperone. Staff had not received training and there was no guidance for staff regarding the expectations of being a chaperone. Staff might not understand what was expected of them and how to advocate for their patient. It was unclear which members of staff would be expected to act as a chaperone.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The clinic was located over 2 floors, the ground floor and the basement. The set of stairs to the basement was very steep and a sign warned people to take care on the stairs. Staff told us where possible patients were seen upstairs and patients with mobility issues would be seen in the upstairs clinic. They reported there had been no accidents on the stairs.

The storage room was in the basement and was filled with boxes of consumables and paperwork. There was no order to how things were stored or evidence of rotation of products. We found out of date consumables including chlorhexidine solution that had expired on 02 October 2025. Cupboard doors were left open and were accessible to anyone in the room and we found equipment had fallen on the floor leading to concerns with infection prevention and control practices. This was not in line with the provider’s medicines management policy. The policy indicated the nurse in charge on duty had overall responsibility, but it was not clear who the nurse in charge was as the nurse manager position no longer existed.

Patients’ paper records were stored in this room. We found the door to the room was not consistently locked and wedged open meaning patient notes were accessible to anyone.

The clinic had a resuscitation trolley located in the theatre. The trolley was broken and being held together with micropore tape. Following our inspection the service advised us that the trolley was due to be fixed within the week, however no evidence of this was provided.

The clinic rooms had privacy screens for patient use when undressing and preparing for an examination providing dignity to patients.

The service used equipment that was maintained by external providers. The quality manager told us different pieces of equipment were managed according to service level agreements with the supplier. If there were any equipment failures the suppliers usually resolved the matter within 24 hours. It was not clear what action would be taken if this time period was not met. We asked to review audits of equipment but these were not provided by the service.

The service carried out an annual audit of staff handling of clinical equipment. This routine audit was caried out by the nurse manager, who had since left. The findings stated that staff were observed using different pieces of equipment correctly and no further action was required. It was not clear who would undertake this audit now the nurse manager had left.

The service had a cleaning schedule SOP which outlined responsibilities for staff but there were no named individuals as required by the SOP. Therefore it was not be clear who the accountable person was for cleaning tasks. However, the practice manager was named as having overall responsibility and the SOP directed staff who to contact if there was an incident involving cleaning providing clear guidance on who to contact.

The service did not always make sure there were qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service did not make sure all staff had received mandatory training before commencing their role. We reviewed the files of 6 members of staff and found there was no evidence that mandatory training had been completed. The registered manager showed us a certificate of the training they had completed online, however this was not dated and it was not clear whether this was in date and when training needed to be renewed. We were sent a copy of a training certificate for a member of staff that showed they had completed training; however this was dated May 2024 and was valid for 1 year and was 7 months out of date at the time of the inspection. We were told that 2 new members of staff had not started mandatory training, despite starting in their role. The service stated they wanted to run a training day covering all mandatory training for all staff to attend. This had not been booked at the time of the inspection. This meant we were not assured staff had received adequate training to carry out their roles safely.

The service did not have a training matrix or log to identify what training staff were required to complete, when it was completed and the frequency it needed to be renewed. This meant leaders did not have oversight of staff staffing and were not aware there were staff who had not received appropriate training. Therefore, we were not assured staff had the necessary skills and knowledge for the roles they were undertaking.

The service had a recruitment SOP which stated an individual programme of induction would be arranged one week before employment started. Staff we spoke with had not received a formal induction and there was no evidence in staff files to show an induction had been completed. The SOP did not outline what an induction would include, therefore it was not clear what staff had to achieve in order to complete an induction. We were not assured staff had received an induction before commencing in their post to ensuring they had the necessary skills for the roles for which they were employed.

The service had a nurse induction and competency SOP to be used alongside the nursing competency SOP. These documents outlined the competencies staff in different roles were expected to complete. Leaders told us staff received internal training and were signed off as competent for procedures and practices; however, this was not documented in the staff files we reviewed, and it was not clear who had completed the competency training. We were not assured staff had been assessed as competent to carry out the roles for which they were employed.

The clinic employed 2 registered nurses, 2 health care assistants and 2 consultants to carry out regulated activity and there were no vacancies. Other staff employed did not participate in activities regulated by the CQC. The registered manager told us they had enough staff to cater for the volume of patients they saw. They would increase staffing levels if required in line with patient numbers. The clinic did not use locum medical staff and patients would only be seen by one of the 2 consultants working at the clinic meaning there was continuity of care. The nursing team did not use agency staff and used bank staff when needed. The practice manager told us they were assured temporary staff were competent to work in the clinic as they were known to the service and worked there regularly, however we did not see evidence of induction or training for bank staff.

The service had a staffing and emergency staff provision SOP which quoted the HFEA code of practice. The SOP indicated the staffing levels were audited by department managers who were responsible for ensuring there were appropriate numbers for the workload and that 2 members of full-time staff in the same department could not take annual leave at the same time. It did not mention how staffing levels would be reviewed if there were any unexpected staff leave for example sickness. Therefore, we were not assured there was a process in place to ensure there were adequate numbers of staff at all times.

The service did not always assess or manage the risk of infection. They did not always control the risk of it spreading.

The environment was not always conducive to infection and prevention and control practice. We observed the recovery area did not have a hand-washing basin for staff to wash their hands after being with a patient. We saw a member of staff leave the clinical area without going into the staff changing room where a sink could be accessed in the toilet. We were not assured staff washed their hands after seeing a patient as the sink was not easily accessible meaning possible infections could be spread.

Clinical staff were bare below elbows at all times during the inspection. We saw the use of personal protective equipment (PPE) and there were supplies in clinical areas. Staff had access to clean scrubs supplied by the clinic reducing the risk of spreading infection.

The clinical areas we saw were visibly clean and tidy. We reviewed the last cleaning audit dated 30 December 2025 which showed a pass mark of 98.11%. All areas were inspected as part of the audit, including equipment and furnishings and given a score out of 5. Areas that scored lower than 5 had a picture attached showing the concern and commentary how it had been resolved, meaning action had been taken immediately.

Staff maintained equipment well and kept it clean. We saw antibacterial wipes available next to the ultrasound machine in both clinic rooms. Staff told us they used these wipes to clean equipment in between patients and there were appropriate bins available for staff to dispose of waste.

Leaders told us they had a service level agreement to dispose of clinical waste. The waste bins were stored outside and were locked so they were not accessible to unauthorised people.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The clinic had a medicine’s fridge for medication requiring storage between the temperature of 2 degrees and 8 degrees. This was located in the storeroom. The fridge temperature checklist was not consistently completed. The check list did not include the temperature range that was considered safe and meant staff might record a temperature without knowing it was not a safe level. This was not in line with the provider’s medicine’s management policy which stated records should be maintained daily when the clinic was open. It also meant that medicines may not be stored at the appropriate temperature which could impact on their effectiveness.

We found out of date medications in the clinic. The resuscitation trolley was located in theatre to be used when needed by all areas of the service. We found an out-of-date epi pen that had expired the month before. This meant in the case of an emergency, a patient might be administered out of date medication that might not be effective. We also found medication that should be stored in the fridge left on top of a cabinet in the storeroom. It was not clear how long this had been left, therefore we were not assured the medication had been stored correctly and was safe to use.

The service used a medicines management competency form which listed a number of competencies for staff to complete. When we reviewed staff files, we did not find a completed form in the 6 employee files we reviewed. The medicines management policy did not mention what training staff were required to undertake. Therefore, we were not assured staff had received training around medicines management giving them the knowledge required to undertake their role safely.

The practice manager told us they had developed relationships with local pharmacies in order to ensure that medications prescribed by the clinic were stocked locally for patients to collect. Patients we spoke with told us they were able to collect medication easily after the appointment.