Archived: The Nimmo Clinic

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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

We looked for evidence that people were protected from abuse and avoidable harm.

The service was in breach of legal regulation in relation to the management of infection prevention and control and medicines.

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.

We did not look at Learning culture during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safe systems, pathways and transitions during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safeguarding during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Involving people to manage risks during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safe environments during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

We did not look at Safe and effective staffing during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

The service did not manage or adequately assess the risk of infection and they did not detect and control the risk of it spreading. The premises appeared generally clean, but we observed some areas were dusty and surfaces in treatment rooms were cluttered. There were cleaning checklists in place but there were no records of these being completed since the end of February 2025. We observed that cleaning supplies were not stored safely. We found that the service did not hold complete records to demonstrate that they were taking the control measures identified as required in their Legionella risk assessment. We also found that where the service recorded water temperatures which were outside of the required range, they took no action to mitigate the risk. (Legionella is a particular bacterium which can contaminate water systems in buildings). We observed that items in cupboards were stored in a haphazard and unsafe way and some consumables were past their expiry date. Waste was not always disposed of appropriately and we observed non-clinical waste disposed of in clinical waste bins. We observed a sheathed needle on the floor in the kitchen. The service had carried out hand hygiene and sharps bin audits which they assessed as satisfactory and failed to identify any concerns. The service had carried out some infection prevention and control audits but these failed to identify all risks and were not accurately completed, as observed during our assessment.

The service failed to implement processes for the proper and safe management of medicines. When we asked, the registered manager, who was also the clinical director, was unable to provide any records relating to the ordering and receiving of medicines or the stock of medicines held within the service. We found that an audit carried out by the service had identified there were no records of medicines received. We asked the registered manager for records relating to the ordering of medicines and they were unable to provide any records. For example, records of individual prescriptions or stock orders sent to pharmacies. The registered manager was unable to clearly describe their processes for obtaining medicines or supplying medicines to patients. During our site visit on 18 March 2025, we saw there were unlabelled boxes of medicines, used for weight loss and weight management, stored within the medicines’ fridge. We observed a single box of medicine for a named patient which had been appropriately labelled by the pharmacy who had dispensed the medicine. During our site visit on 18 March 2025, we observed a box of prescription only medicine, a medicine used for weight loss and weight management, being handed to a patient with none of the labelling required by law for prescription only medicines, such as the name of the person the medicine was prescribed for and dosage instructions.

Medicines that required refrigeration were stored securely in a lockable fridge. However, the temperature of the fridge was not monitored appropriately. The registered manager told us that temperatures were not checked regularly and that they relied on the fridge alarm sounding to alert them that the temperature was out of range. We asked the registered manager at what temperatures the alarm would sound, and they told us they did not know. There was an integral temperature recording device from which data could be downloaded. On the days of our site visits, 18 and 20 March 2025, the registered manager was unable to provide those downloaded records. However, following our visits they provided a sample of records but no evidence that those logs were being routinely reviewed. The registered manager told us there had been no occasions in the last year when the fridge temperature had been out of range. However, when we reviewed the data provided, we found evidence that some temperatures recorded were outside the safe storage range for the medicines stored within the fridge. We saw evidence that at times, the recorded fridge temperatures were 0 degrees Celsius and 8.5 degrees Celsius. These medicines should be protected from freezing, as freezing can render them unsafe to use even if then thawed. The records showed that the main fridge alarm did not sound when the temperature was recorded below 2 degrees Celsius or above 8 degrees Celsius (the appropriate temperature range for the storage of the medicines we found), which further demonstrated the service’s failure to implement a reliable method to monitor the fridge temperatures.

We reviewed a sample of clinical records and found that in multiple cases, patients had commenced treatment and prescriptions had been issued, with no corresponding consultation notes documented. This meant the service was unable to demonstrate they had provided care and treatment in a safe way. For those patients, there was no record that the patient had been assessed prior to treatment; whether the suitability of the medicine prescribed for the patient had been considered; that other treatment options had been discussed, or that a clear treatment plan had been developed. We asked the registered manager, who was prescribing medicines for weight loss and weight management, whether they would recognise the symptoms or any indications that a patient may have an eating disorder, and they told us that they would not. For patients accessing weight loss treatments, the service was unable to demonstrate they had received sufficient information regarding the risks and benefits of the proposed treatment, to enable them to give their informed consent to the treatment. The registered manager was unable to demonstrate whether they had prescribed the medicine in line with the product licence or best practice guidance, or that they had informed the patient if they had not. For those patients, there was no evidence that the service had provided information on how to access support should they experience side effects from the medicine, in particular when the service was closed.

Some clinical records we reviewed showed consultations had been more thoroughly documented and those patients were advised to contact the service with any questions or if they experienced any side effects. However, for those patients, we again saw no signposting information was provided for patients should they experience side effects from the medicines or have concerns whilst the service was closed.

The registered manager told us they were ‘signed up’ to receive safety alerts and medicine recalls but was unable to describe how they would take action if required. We found that the service was not recording details of medicines held or used by the service or in some cases those medicines provided to patients, which meant they would be unable to determine whether they were affected by safety alerts or medicines recalls.