Regent Street 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 rated 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 safe care and treatment, specifically, assessing the risks to the health and safety of service users of receiving the care or treatment, and the proper and safe use of medicines.

This service scored 50 (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. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. However, people did not always feel they could speak up and that their voice would be heard. Feedback received prior to and after our assessment from whistleblowers indicated some people felt unable to challenge leaders whilst employed at the service as this would lead to contract termination without cause.

The provider had processes for staff to report incidents, near misses and safety events. The registered manager shared notifications relating to reported cases of global infectious diseases to aid consultations. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. Whilst patients were asked if they consented to sharing information with their GP, there was no process for ensuring this was shared with other agencies such as NHS GP to ensure they are aware of information which has an impact on safety. For example, when medicines were prescribed for weight loss, where people are seen over a period time during their treatment, which have a significant side effect and contraindication profile.

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. Staff told us they shared concerns quickly and appropriately internally to their safeguarding leads. However, they did not have information on how to contact safeguarding boards local to the clinics they operated in. The provider immediately placed local safeguarding contact details in each clinic in case of urgent concerns.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

Regent Street Clinic is an independent health service. They are a provider of private health services which include travel vaccinations, remote GP consultations, sexual health, health screening, hayfever treatment, aesthetics, medicals, occupational health and counselling services. The service does not see people on an ongoing basis for their care and treatment, or people acutely unwell who require urgent care. This quality statement is not relevant for this service.

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. This was a breach of regulation 12 safe care and treatment. For example, trip hazards at one site from wires and a deep pile rug in the clinical room had not been risk assessed, and we observed full sharps boxes kept on the floor at two clinics. A fire door was wedged open. We received assurances after our assessment of actions taken to remedy our findings. Additionally, the provider had engaged a Health and Safety consultant who in the process of visiting each clinic to conduct audits specific to each site and identify any risks.

Emergency equipment was not robustly monitored. We found there were no child oxygen masks at two clinics and one clinic had empty oxygen tank. The provider immediately implemented child masks at all clinics and replaced the oxygen tank.

We found personal safety arrangements required review at some clinics which were operated by lone working staff. Whilst we were assured staff informed management as soon as they arrived at a site, the provider took steps to provide lone workers with personal safety alarms and reviewed their safety at work policy.

We received concerns regarding staff training, and clinicians potentially working outside the scope of their practice. These were significant as nursing staff assessed patients face to face and a decision on appropriate management was often decided virtually by a clinician who had not seen the patient face to face.

During our assessment, we found training for clinicians on procedures such as intradermal administration, sexual health, cervical screening was all delivered in-house by the lead clinician. This involved an examination and competency was assessed through supervised practice. Following our assessment, all practice nurses were enrolled for an Royal College of Nursing accredited course in minor ailments. The provider also obtained certification of membership for providing continuous professional development training, to accredit their training.

The lead clinician provided evidence of their qualifications, skills and experience enabling them to provide training. There were regular virtual training sessions on specific topics, and daily communications with staff through the Google Meet platform. We saw evidence that clinicians conducting competency based procedure procedures such as cervical screening had received training from both the provider and external bodies such as the NHS, and training was based on national good practice guidance. However, the provider conducted a very low number of such procedures (three completed in the 12 months preceding our inspection) at their clinic sites.

Following our assessment, the provider immediately arranged for training from external providers for all their clinicians in minor ailments treatment. They further obtained membership to a CPD accreditation service in November 2025. This means they now provide training recognised independent CPD accreditation, compatible with global CPD principles.

The management of staff recruitment files had improved; these were now accessible and demonstrated appropriate checks undertaken at the point of employment.

The service did not always assess or manage the risk of infection. Arrangements for infection prevention and control (IPC) required review. The policy had not been adhered to in respect of annual audits and how these would be carried out at all clinics. There was no robust system for monitoring cleaning at the satellite clinics. Consultation rooms had a mix of fabric and wipeable surfaces; there were no documented risk assessments to mitigate potential risks of infection in line with infection control guidance. At one satellite clinic, we found cleaning arrangements were either not in place or not followed, and staff were unaware of any specific cleaning schedules. However, the provider showed us evidence an audit from an external company was already planned and was conducted at the main location in Nottingham during the period of our assessment. They told us they were working to meet actions identified in the audit and consider how these would be replicated across all satellite clinics to promote consistency in IPC practice.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules on electronic spreadsheets and paper forms were implemented following our assessment, with plans for the lead to monitor these for each clinic through inspection.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There were some improvements in respect of medicines management areas we reviewed at our last assessment in 2024. For example, a medicines stock control system was now in place to monitor medicines received, batch numbers and medicines used. There were improvements in cold chain management including transportation arrangements for medicines which required refrigeration. However, we found that not all staff were aware how to reset the medicines fridges and some data loggers had not been checked. Training on this was immediately reinforced with all staff.

At this assessment, we found new concerns relating to medicines management, which were not covered in our previous focused assessment. These represented a breach of regulation 12 (safe care and treatment).

Systems and processes for checking emergency medicines and equipment were suitable for use were not implemented. We saw that some medicines for use in an emergency were expired and that some of the required medicines and equipment was not available onsite. The impact of this was that the service could not be assured that patients could be safely treated in an emergency. The provider responded to this by reviewing their emergency medicines and equipment checklist within their medicines policy.

Medicines security had not been adequately risk assessed at some of the clinic sites. We found some treatment rooms were unlocked, keys were left in situ in a medicines fridge and some medicines were kept in unlocked cupboards. The service remedied this immediately after our visits by installing door locks and lock boxes for fridge keys.

We identified potential record keeping concerns regarding both written and electronic records. Following administration of vaccines accurate records were not always made in patients’ records. We observed variations in the issuance of travel booklets to people receiving vaccines. At one clinic, a patient was not given out a travel booklet as the nurse stated it was only given out once all the jabs were given, so that they could record all batch numbers in there. This was not the case at another clinic where a patient in the waiting room attending for another course of rabies vaccine had their travel booklet. This presented a potential governance concern due to the lack of consistency in how clinicians operated across clinic sites, despite receiving the same training. Following our assessment, the provider gave assurances of how this had been addressed with the individual staff concerned.

The provider’s policy on the administration of Kenalog (a medicine used to treat severe inflammation, allergies, and specifically severe hay fever) did not state if the medicine was given in quantities which require patients to be issued with a steroid card, in line with a patient safety alert previously issued on this. The provider had no process for recording and learning from medicines errors or incidents. No system was in place to review or audit prescribing at the clinic.

We found some Patient Group Directions (PGDs) to authorise the administration of vaccinations had not been signed by the authoriser at the time the clinicians signed them, in line with legal requirements. Some nurses did not have access or could not tell us how to access PGDs when administering vaccinations. The provider immediately reviewed the system for authorising PGDs.