Sister Kate 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 requires improvement.

The service was in breach of legal regulation in relation to Regulation 12 Safe Care and Treatment, Regulation 18 Staffing and Regulation 19 Fit and Proper Persons Employed.

This service scored 62 (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.

Staff told us people were supported to raise concerns. There was an open culture, and safety was a top priority. The provider encouraged staff to raise concerns when things went wrong. Patient safety and clinical activity was discussed during clinical meetings. The provider had processes for staff to report incidents, near misses and safety events. Although outlined in the incident reporting and investigation policy, a form for recording significant events was not available. There had not been any significant events or any complaints received during the previous 12 months.

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 people. People referred themselves to the service and were assessed to determine if their needs could be safely met. People could book online, call or send an email. The provider had an online system for storing documents and information about people.

The provider told us that most people did not require any follow-up with the service. There may be occasions when this was necessary, such as if the wax was very hard and people were offered appointments within a few days of their initial visit.

The service worked with other providers to deliver shared care and when people moved between services. Referrals back to the person’s own GP 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 provider had a safeguarding policy, which identified potential safeguarding concerns and how these should be responded to. The provider knew where to access the contact details of statutory organisations, in the event that the provider needed to make a safeguarding referral or ask for advice if there were any safeguarding concerns.

Staff had completed Level 2 safeguarding training for both adults and children. The provider was advised to complete Level 3 safeguarding training for adults and children as required as they provided an ear wax removal service to both adults and children. Following our assessment, the provider sent us evidence that they had completed this training.

The provider had made no safeguarding referrals.

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.

Staff completed an assessment, including of risk, at the beginning of each person’s visit to the service. This included identifying any medical history, potential infections or other risks that may delay or prevent treatment from being carried out.

Staff had received training in basic life support (BLS) at level 2 for adults and children. In the event of a medical emergency the service would call 999. Staff knew how to access a nearby public defibrillator if necessary.

The provider was a registered nurse, and the staff member had previously worked in the NHS as a health care assistant. Staff could recognise a deteriorating patient and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.

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 provider was responsible for the maintenance and health and safety within their own clinical area. We saw that portable appliance testing (PAT) of electrical items had been completed. Policies to ensure the safety of the service were in place. However, relevant risk assessments had not been completed. For example, for the environment, and when working away from the main site (home visits, satellite sites and visits to a local college). Following our assessment, the provider shared a risk assessment for completion when working away from the main site.

The landlord of the premises was responsible for building maintenance, emergency lighting and fire safety. Not all records were available during our visit, and the provider had had not assured themselves these checks had taken place. For example, the most recent fire risk assessment seen was dated April 2024 (for review April 2025) and contained actions that should been addressed within one month. There was no evidence to support these actions had been completed. Following our assessment, the provider shared information from the landlord that the fire risk assessment had not been repeated or all of the identified actions completed.

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

Although the service made sure there were enough staff, they were unable to demonstrate staff were qualified, skilled and experienced. They could not evidence staff received effective support, supervision and development. However, staff did work together well to provide safe care that met people’s individual needs.

The provider employed one member of staff. A staff recruitment policy was in place; however, the provider was not working in line with this policy as none of the required recruitment information was available for the member of staff employed.

The provider told us staff had completed an accredited diploma course in micro suction, however certificates to support this training were not available. We were told staff worked within their agreed areas of competence and supervision took place. Written records to support this were not available, and an appraisal had not been completed for the member of staff employed. The majority of staff training was up to date, although not all staff had completed training on learning disability and autism or the mental capacity act.

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 staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The provider was responsible for the cleanliness of the room that they rented. This area was clean and well maintained. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. Staff cleaned equipment after contact. Staff followed infection control principles including the use of personal protective equipment (PPE). PPE such as gloves and aprons were readily available. Clinical waste was stored in an external locked bin, although the bin itself was not structurally secured.

The provider used cleaning products provided by the landlord in addition to products purchased directly. The provider did not have a Control of Substances Hazardous to Health (COSHH) policy or risk assessments in place, and the product data sheets were not available. Data product sheets were obtained from the landlord during our assessment.

The landlord was responsible for the routine legionella risk assessment /prevention strategy. The provider had not assured themselves that the landlord followed the routine legionella prevention strategies as they did not have access to all relevant records. Following our assessment, the provider shared information from the landlord that a routine legionella risk assessment /prevention strategy was not in place. As a consequence, the provider had completed their own interim legionella risk assessment, to manage the risks within their control, for example, checking water temperatures.

The provider ran the water outlets in the building on a regular basis.

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.

No medicines were kept on site. The provider had a range of relevant products to show people when they visited the clinic. Clear advice was given to people about suitable products to purchase to help soften ear wax or protect the ears when swimming.

If the provider identified a medical problem that needed further attention, they advised the person to seek medical treatment, such as from their GP. With people’ consent, they wrote to the person’s GP with their findings and requested follow up appointment were appropriate.