SH Medical Clinic

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 safe and effective staffing.

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 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. The provider undertook an annual people feedback survey and produced an overview that identified key learning points. These learning points were discussed within staff meetings. Records of staff meetings also showed discussions included the introduction of new memberships, product promotions and new treatments, with clear action points assigned to support staff readiness and to ensure accurate and consistent communication with people. The provider had systems in place for staff to report incidents, near misses and safety events. There was a process to record and investigate complaints, and staff understood the importance of responding openly when things went wrong. We saw evidence that apologies were offered and appropriate support was provided to people affected. The provider was able to demonstrate learning from incidents and complaints had led to improvements in people’s care. For example, changes had been made to the review of medical forms prior to appointments to ensure information was accurate and complete before procedures were undertaken.

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. The service worked with other providers to deliver shared care and when people moved between services. Such as, with consent, clinical updates and summary letters can be sent to the person's NHS GP as needed. 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 were available and known to staff, who were trained in safeguarding procedures.

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. Emergency equipment was available and maintained. Staff could recognise a deteriorating person 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.

Whilst contracts were in place to support the ongoing maintenance of the premises, the provider did not always ensure cleaning records were available to demonstrate cleaning tasks were completed in line with required standards. Additionally, the provider lacked the necessary safety data sheets for cleaning materials, which are essential for managing potential hazards and ensuring the safe use of substances within the environment.

The service provided evidence to confirm a Legionella test was carried out in 2024; however, the certificate did not specify the result of the test. The provider has since arranged for a further Legionella test, with results pending, and has requested the risk assessment documentation from the company responsible for the testing.

Fire safety equipment was subject to regular checks and testing, and appropriate documentation was in place. However, although the service’s fire policy referenced that a fire risk assessment was in place, this had not been completed. The provider has confirmed, since our onsite visit, a fire risk assessment had been completed.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The service only employed 2 staff members, but the provider could not provide evidence to show proper recruitment and employment checks had been undertaken, as outlined in Schedule 3 of the Health and Social Care Act. Whilst all mandatory training had been completed, evidence seen indicated this was undertaken only after our announcement of the inspection. The provider confirmed this was the case and, in an attempt, to stop this from happening again the provider had introduced reminder systems to ensure staff training is kept up to date and maintained on an ongoing basis. The provider had a policy mentioning staff supervision and appraisal, but these were not implemented. However the provider was able to show evidence of an external appraisal conducted by a local NHS nurse, which took place in November 2025.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. While the service had appointed an infection prevention and control lead and ensured all staff received appropriate training, there were gaps in assurance processes. Cleaning schedules were not present, meaning the provider could not be confident that all necessary cleaning tasks were undertaken. The provider has since submitted evidence confirming the implementation of these schedules.

However, hand hygiene audits were conducted regularly, with the most recent completed in November 2025. Clinical waste equipment, for example, clinical sharps bins, were in place and all clinical rooms were fitted with hard flooring to facilitate effective cleaning. The use of ‘I am clean’ stickers on recently cleaned equipment was observed. The environment of the service was observed to be visibly clean during our onsite visit, and appeared to be well-maintained.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Medicines were managed safely and effectively within the service. Staff were trained in medicines optimisation, with regular competency assessments to ensure they were confident in the storage, administration and recording of medicines. Prescription stationery was handled securely and appropriately. Medicines, including controlled drugs and emergency medicines, were stored securely at suitable temperatures, with regular checks of stock levels and expiry dates. Medical gases such as oxygen were stored safely, and relevant safety risk assessments were completed. The provider had a system for receiving safety alerts and medicine recalls. However, in response to not actioning the Medicines and Healthcare products Regulatory Agency (MHRA) alert issued in 2022 regarding the advertisement of the use of ‘Kenalog’ injection (a hay fever injection), the provider was asked to remove all information relating to ‘Kenalog’ injection from their website and leaflets in the waiting room. The provider had not ensured compliance with the national guidance prohibiting the direct or indirect advertisement of that particular prescription-only medicine to the public. The provider actioned the removal immediately during our onsite visit. People using the service were informed about what to do and whom to contact if their condition did not improve or if they experienced unexpected symptoms.