Functional Doctor Ltd

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. This key question has been rated as Good.

This service scored 75 (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 was run by a single-handed doctor, and they employed a part time receptionist. The service encouraged staff to raise concerns when things went wrong.

We found that safety was a top priority and the provider had processes in place to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints 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 and procedures were in place. Staff had received appropriate safeguarding training and were able to describe the procedures to follow if they had safeguarding concerns. The service provided treatments to both children (3 years and over) and adults. Systems were in place to verify patients’ identities. Where children attended the service, processes were in place to ensure that any accompanying adult had appropriate parental responsibility.

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 lead doctor was suitably trained in emergency procedures. Emergency medicines and emergency equipment were checked regularly. The service carried out a risk assessment and initially decided not to keep an Automated External Defibrillator (AED) on site. However, following the inspection, the service informed us that a new defibrillator had been ordered.

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

The fire risk assessment was carried out by an external contractor in February 2026. The fire system was inspected regularly; the fire extinguishers were checked and there was a record of fire alarm checks. The service carried out regular fire drills.

Portable appliance testing was carried out in February 2026.

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

A gas safety check was carried out on 2 February 2026.

The fixed electrical installation checks of the premises had been carried out on 30 April 2022.

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

The service was operated by a sole doctor, supported by a part-time receptionist. Despite the small team, appropriate arrangements were in place to ensure the doctor was qualified, skilled, and experienced, with access to necessary support and professional development. They worked effectively together to provide safe care tailored to people’s individual needs.We found staff training was up to date and learning needs of staff was managed appropriately, and staff were working within their agreed areas of competence. We reviewed 1 staff file and found recruitment checks were carried out in accordance with regulatory requirements, including Disclosure and Barring Service (DBS) checks. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

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

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.

The service displayed hand washing poster after the inspection and had implemented a stricter rotation for the disposal of sharps bins.

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 5 clinical records, which were 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.

The service provided patient care by combining functional medicine with a conventional medical approach. It focused on supporting lifestyle changes, alongside the use of nutrition and supplements. The service did not provide treatment for acute conditions.

The service prescribed some unlicensed medicines, which were supplied by specialist pharmacies in the UK. The associated risks were explained to patients, and appropriate consent was obtained and documented.

The service did not use a medical refrigerator on the premises.

Staff regularly checked the stock levels and expiry dates for emergency medicines.

The service stored medical gases, such as oxygen, safely and completed the required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls.