108 Medical Limited - Harley Street

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

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. The service worked with people and other healthcare organisations to understand what is safe care and treatment and the best way to deliver safe care and treatment. Staff managed medicines well and involved people in planning any changes to their treatment.

The service was previously inspected under the old methodology in 2013 and was assessed as meeting all standards.

This is the first rated assessment for 108 Medical – Harley Street service. This key question was rated good. This meant people were safe and protected from avoidable harm.

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.

The service had appropriate systems and processes for staff to report incidents including near misses and for these to be acted upon. Managers had oversight of all reported incidents to identify themes and trends. There were policies and processes for staff to follow when reporting incidents. They explained how to report, categorise, and investigate incidents. Staff said they were encouraged to report incidents promptly. They knew what incidents to report and how to report them and did so in line with providers policy. Staff told us they received feedback from incidents they reported, and learning from incidents was shared in meetings and by email. Staff were informed about the incidents and lessons learnt, including details of actions taken, by use of posters on the notice board in staff rooms.

Staff we spoke with gave an example of a historic radiology reporting incident which happened in 2023. They told us following this incident, senior staff reiterated the checking processes around Radiologist reporting. The service had not reported any serious incidents in the last twelve months; however, minor incidents were reported. These incidents were investigated by the manager, and the action plans we shaw following an incident demonstrated learning from incidents and concerns.

There was a duty of candour policy and staff understood the importance of duty of candour. Staff we spoke with told us no serious incidents had occurred where it needed to be used.

The service worked with people to establish and maintain safe systems of care, in which safety was managed or monitored.

Staff held weekly multidisciplinary meetings to discuss all patients seen at the clinic to improve their care. Patients had their care and treatment reviewed by their consultants depending on their care needs.

Radiographers, who provided diagnostic imaging to patients ensured good standards of radiation safety. They used national diagnostic reference levels (DRLs), these were safe radiation doses used in medical imaging to help optimize patient exposure to radiation. We noted that all DRLs were within acceptable safe thresholds. This provided assurance that patients received minimal exposure.

As the provider did not have the facilities to operate at the clinic, they had a service level agreement with a local independent hospital for patients who required a surgical procedure as part of their treatment. There was a standard operating procedure in place which detailed the process for staff to follow if a patient required surgery following their consultation at the service, this included referrals, admissions and discharge where patients were moving between services. Staff shared information about patients’ treatment appropriately with relevant healthcare professionals, such as their GP.

Patient care was coordinated with the independent hospital which enabled a smooth transfer of patients between the two services. The service was organised to manage patients who needed surgery at the independent hospital to continue their care and treatment at the independent hospital without disruption.

The service worked with people to understand what being safe meant to them and the best way to achieve that.

All staff had completed both safeguarding adults and children level 2 training as a minimum; this was in line with their roles and the provider’s policy. We saw the service training matrix which showed nurses and clinicians had completed safeguarding level 2 & 3 training. The clinic manager was the safeguarding lead and completed level 4 safeguarding training. The manager provided guidance and oversight for safeguarding issues.

All the staff we spoke with demonstrated a knowledge of safeguarding principles, signs and risks and knew how to adapt patients care to keep people safe from harm. For example, staff understood the wide range of cultures and religions to which patients belonged and knew how to identify unusual risks outside of these norms. Staff had researched, tested, and implemented discreet communication systems for people to get help such as in instances of domestic violence or human trafficking.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under The Equality Act.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. A safeguarding escalation system was in place that included information about contact details of the local authority safeguarding team, and staff we spoke with knew how to use this. The safeguarding lead told us safeguarding incidents were rare at the service and staff used case studies and scenarios to ensure they remained vigilant and aware. There were no safeguarding referrals in the last year.

Chaperone training was part of the provider’s mandatory training. We were told most of the clinical staff were trained to act as chaperones on request. Patients were provided with information about chaperone and could request a chaperone at the time of booking their appointment. They had a choice of male or female chaperone to choose from. The booking team checked this in advance so that a chaperone could be arranged before the patient arrived for their appointment. Staff also requested chaperones where they felt this was necessary. We were told staff signed and dated chaperone documentation when they had been present for an appointment.

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

The service assessed patient’s individual needs and risks using a recognised tool which was reviewed regularly, these assessment records were part of the records we reviewed during the onsite inspection. Clinicians completed an assessment of each patient at the booking stage, which included a triage process to assess appropriateness of their care and treatment. This assessment was ongoing throughout the person’s time with the service.

Clinical staff met daily before the start of service to discuss the treatments booked for the day, any capacity or staffing issues or any pressures on the service. These were recorded in the service diary.

The clinic manager told us that staff shared key information to keep patients safe when handing over their care to others. Consultants, nurses, radiographers and sonographers provided handover information in line with treatment plans.

All staff were trained in life support to a level appropriate for their role. Non-clinical staff completed basic life support (BLS) training. Nurses and consultants completed intermediate life support (ILS) training. Mandatory Training records showed 98% of staff had completed their mandatory training this was above the provider’s target of 95%.

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

The service had enough suitable equipment to help them to safely care for patients, staff were trained in its use and kept equipment clean and well maintained. All equipment was noted to have green “I am clean stickers.” Portable electronic equipment had been safety tested, and evidence of when equipment was next due to be serviced was visible on equipment.

The environment was visibly clean and clutter free with furnishings in a good state of repair. Staff disposed of clinical waste safely. The domestic and clinical waste bins were clearly identified and emptied regularly. Sharps and hazardous waste bins were labelled correctly and closed when not in use.

The service had suitable facilities to meet the needs of patients' and their families. All areas of the service were accessible by an elevator. Waiting rooms were spacious and well equipped with hot and cold refreshments.

Staff told us they checked equipment was in good working order at the start of each day. They also checked oxygen cylinders to ensure they were stored in line with national guidance and maintained above minimum volume. Staff documented a range of safety checks on emergency equipment, these checks included daily weekly, monthly, and annual audits to ensure equipment and consumables were up to date.

We observed the premises were visibly cleaned and well maintained. Patients told us the premises and equipment were visibly clean and tidy, and they did not have any concerns relating to the cleanliness of the environment and equipment.

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.

The service had enough nursing, medical and allied healthcare staff with the right qualifications, skills, training, and experience to provide the right care and treatment.

Staffing levels were planned to reflect the number of clinics being run for the day. We were told staff on shift reflected the number of nurses, radiographers and sonographers planned to cover the number of clinics running. Staff absence was covered by substantive staff who worked extra hours or an extra shift. The service did not use agency staffing. We saw all staff in the department, including administration staff and radiographers, worked well together to provide safe care.

At the time of our visit, the service had no vacancies, it had not reported their sickness rate, so we were unable to assess workforce resilience over time. All staff participated in an annual appraisal and had the opportunity to discuss any concerns or professional development opportunities with their line managers. Managers monitored staff compliance with training and ensured staff were competent to undertake their roles. The review of training documents we undertook showed the provider had a training compliance rate of 98%, which was above their target of 95% for both training and annual appraisal completion.

Staff had completed mandatory training courses in key skills including manual handling, health and safety, infection control, conflict resolution, equality, diversity and human rights, fire safety, information governance and data security, preventing radicalisation, resuscitation, safeguarding vulnerable adults and safeguarding children. Training data showed all imaging staff had completed role-specific mandatory training including Ionising Radiation Medical Exposure (IRMER), patient safety and in-house competencies. This training ensured clinician were competent and their role and were aware of radiation reference levels and safe radiation doses.

The service had processes to ensure staff were recruited safely and received training in line with their roles. Recruitment checks undertaken included references, DBS and professional registration checks. The service had evidence that all pre-employment checks had been completed.

Consultant surgeons worked under practising privileges. The medical advisory committee chair monitored compliance with surgeons practising privileges contract. Surgeons were granted practicing privileges following recommendations from the medical advisory committee. The medical director reviewed all surgeons' files to ensure they were compliant with the terms and conditions of their practising privileges yearly.

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.

There were clear roles and responsibilities around infection prevention and control. Staff completed daily cleaning checklists to record compliance with cleaning schedules and standards of the environment. Data showed 98% of staff had completed their infection prevention and control mandatory training, which was above the provider’s compliance target of 95%.

We observed staff followed infection control principles including the use of personal protective equipment. Hand-washing and sanitising facilities were available for staff and visitors throughout.

The service performed well for cleanliness and hand hygiene audits. The service reported a compliance rate of above 95% for weekly infection prevention and control audits for April, May, June and July 2025. However, the quarterly infection prevention and control audit for April 2025 had compliance of 98%. The action plan developed post this audit included areas for improvement and the actions to address these. The action plan was monitored by the manager; we were told all the actions in the action plan had been completed.

The service had infection prevention and control (IPC) policies which guided staff on processes and practices such as hand hygiene, cleaning of the minor operation room. Staff we spoke with told us they were aware of these policies and knew how to access them. The clinic manager was the IPC lead who oversaw infection control processes and provided support for staff.

We observed staff following hand hygiene and 'bare below the elbow' guidance appropriately. Staff were observed wearing personal protective equipment, such as gloves and aprons when delivering care and disposed them correctly after use.

The service had processes in place to monitor outcomes and post-operative infections. For example, the service completed audits and surveillance of surgical site infections (SSI’s) and worked collaboratively with the independent hospital’s IPC team to monitor outcomes and investigate readmissions for SSIs, these showed the 2 services collaborated to mitigate and prevent the risk of infections.

The service made sure that medicines and treatments were safe and met people’s needs.

Staff followed systems and processes when prescribing, administering, recording and storing medicines. Staff audited standards of medicine prescribing practice at the service monthly, to check compliance with best practice guidance issued by the British National Formulary, Nursing & Midwifery Council and provider medicines management policy.

We noted the only medicines stored on site were local anaesthetic drugs used for minor operations. These were stored in a locked cupboard in a locked room. The medicines cupboard was only accessible to trained clinical staff. The service did not stock control drugs (CD), therefore did not require a Home Office licence for these medicines.

The service had systems to ensure staff were made aware of safety alerts published by Medicines and Healthcare products Regulatory Agency (MHRA), to ensure the service was compliant with MHRA regulations. The lead nurse led this process and ensured updates were understood by the team by the lead nurse.