Archived: The Sanctum

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first assessment of this service since its registration with CQC. This key question has been rated as Inadequate

Our assessment found that the systems and processes to ensure safe management and use of medicines were not safe.

The provider’s medicines policy was in date; however, the policy itself was not service specific and did not provide sufficient detail to ensure staff knew the provider’s expectations regarding medicines management and use. For example, the policy did not describe the expectations for temperature monitoring of the medicines fridge. As a result, when we looked the fridge records, we could see that out-of-range information had been recorded but no actions taken. We discussed this with the manager who stated that it had been a recording error and that this would be rectified. On the day of the inspection the temperature was in the correct range.

The medicines policy did not guide staff to other relevant policies the service had, such as their weight loss policy or intravenous policy. The weight loss policy was comprehensive and contained sufficient information to support safe prescribing of weight loss medicines; however, when we reviewed clinical records, the policy was not being followed by staff. For example, we saw medicines in the cupboard for 1 person who had no record of attending the service in the Another person had a clinical record but there was no weight loss records within their notes.

The service provided intravenous, subcutaneous and intramuscular injections/infusions. Policies were in place; however, they were generic and did not provide detail for the treatments provided at the service. There were no protocols in place for specific treatments to ensure these were administered safely. For example, the service provided vitamin and well-being treatments, however, there were no protocols on how these should be administered.

We had concerns about the process used at the service for purchasing medicines and items used to administer medicines. Private prescriptions were used to purchase medicines for individual people which were then used as stock medicines for other people who these medicines were not prescribed for m. Clinical records for people who had been prescribed medicines were not always in place. For example, we saw 1 box of weight loss injection for 1 person who did not have a clinical record at the service. Other people had medicines in the cupboards but there was no record of the person ever attending the service for that treatment. For some people who had medicines at the service their electronic clinical record did not have sufficient information to enable safe prescribing. For example, there were multiple people with children’s dates of birth. The service is not registered for children’s services.

In almost all records we reviewed there were no prescriptions uploaded even though the system had an area for prescriptions to be held. The provider could therefore not demonstrate that medicines administered were prescribed, obtained or recorded correctly for the people who attended the service.

Medicines were not always stored securely or appropriately. We saw in clinical rooms that medicines were stored in unlocked cupboards. We saw pots of white cream with no labels. We were told this was numbing cream, used prior to procedures to numb the area to be injected, that was decanted from a bigger pot into small pots for use. There were no records of this decanting occurring, no batch numbers and no identifiable information on the small pots. We saw that slimming injections for 2 people were stored on a shelf above the fridge and not as they should have been in the fridge.

We saw in 1 clinical room a veterinary intravenous venous (IV) set which clearly stated for Veterinary use only. We were told that this had been purchased as it was the same as any other IV set. No further information could be provided that this was safe to use in humans. We could not see in records that informed consent had been obtained to use this product.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Our assessment found the care and treatment people received did not meet the expected standards relating to assessing people’s needs.

Some staff told us that they would not carry out a regulated activity if they did not feel that the assessment of the person showed it was safe to do so. However, there was no system for recording this and no evidence to show that treatment was refused or postponed.

People provided medical information to the practitioner delivering the regulated activity through a medical questionnaire. However, the information requested was limited and there was a lack of evidence of further thorough and effective assessment prior to treatment to ensure people’s needs were fully understood. For example, in 6 records that we looked at, the person’s accurate date of birth had not been recorded. Four people had a date of birth recorded as 1/1/2016 one person had a date of birth as 1/1/2017 and one person had a date of birth as 1/1/2024.

Information and assessment outcomes were not shared with the GP or other relevant health and social care agencies. This included prior to minor surgery where the staff stated that patients were asked to consult their GP prior to procedure to ensure that the surgery could take place. However, there was no evidence of this taking place. The consent to share information post procedure was not recorded as having been asked for. This meant there was a risk important information would not be safely shared between health professionals.

Staff told us that they made people aware of some potential risks and side effects when assessing and delivering treatment, however the service did not have any inclusion/exclusion criteria for treatment and there were no records to demonstrate safety netting. (Safety nettinginvolves ensuring that systems are in place to provide safe monitoring and follow-up, as well as the specific advice given toindividualpeople). Records that we looked at corroborated this.

The service provided minor surgical procedures, some clinical records were of a comprehensive nature with detailed diagrams, prescribing and clinical information. Other records however lacked significant information. For example, there was no information regarding the use of local anaesthetic which was used during the minor surgical procedures performed at the service. In 1 case antibiotics were given but there was no record of what these were or how long they were given for and there was no prescription uploaded. Additionally, where consultations recorded a post procedure assessment was needed some records did not document that this occurred, and others held inaccurate information or missing information. For example, 1 person’s record stated they received 7 sutures during the procedure but at follow up only 5 were recorded as removed and no record was made to account for the other 2 sutures. This meant the service could not account for the remaining sutures, failure to maintain accurate records places people who use the service at risk of harm.

Systems and processes were not in place to ensure people received care, treatment and support that was evidence-based and in line with good practice standards.

Staff we spoke to were not familiar with changes in clinical guidelines. There was no system in place to cascade or disseminate this information to clinical staff who may have needed it.

The service was providing intravenous fluid therapy for people with Postural Orthostatic Tachycardia Syndrome (POTs). We were told that patients were referred to the service by a consultant, however, there was no evidence in people’s records of this referral. Staff told us that they had a comprehensive written protocol in place for the treatment of this condition, however, were unable to provide us with this protocol. Clinical records for 1 person showed that they had received their fluids over a range of time scales from 2 hours up to 4 hours. The provider could not demonstrate that the staff were administering this safely.

The service had a weight loss policy, decision tree and standard operating procedure for staff to follow when conducting weight loss consultations. We were told that some people came to the service to be injected as they were uncomfortable injecting themselves. However, it was evident from clinical records that the policies were not being followed. For example, 1 person had medicines at the service but on the electronic clinical record system there were no records to show that any consultation for weight loss had occurred, another person was not on the clinical system at all.

The service offered a variety of clinical procedures however no protocols or guidance was available to staff on how to safely administer these medicines and no audit work had been completed to ensure that these were being completed safely and competently.

Staff did not have access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. Health assessments of patients were limited in scope, and there was no request for consent to the sharing of information between professionals or stakeholders. Our review of people's records did not evidence letters sent to the person’s registered GP in line with Nursing and Midwifery Council guidance. There was no evidence to show that the risks of not sharing this information had been explained to people.

When people received care, it was not coordinated effectively. For example, we saw written records that did not adequately describe the treatment or intervention (regulated activity) that had been carried out. This meant that only the individual practitioner had knowledge of the person and the treatment they had received. This posed a risk if a different practitioner was to be allocated the person to treat, due to staff absence or their leaving the service.

Staff did not work collaboratively to understand and meet people's needs because there was no evidence of effective clinical supervision.

Our assessment found the care and treatment people received did not meet the expected standards relating to supporting people to live healthier lives.

Some staff told us that they would not carry out regulated activity if they did not feel that the assessment of the person showed it was safe to do so. However, there was no system for recording this and no evidence to show that this treatment was refused or postponed.

Effective systems and processes to support people to manage their health and wellbeing and, where possible, to live healthier lives were not in place. Assessments did not adequately consider the person’s health, care, or wellbeing to enable them to receive care or treatment that had the best possible longer-term health outcomes.

Our assessment found the care and treatment people received did not meet the expected standards relating to monitoring and improving outcomes.

Staff we spoke to told us they were not involved in clinical audit.

The provider was not actively involved in quality improvement activity. There was no clinical audit system and no system in place to use information about care and treatment to make improvements. The provider did not have evidence of guidance documents used by staff for the regulated activities they delivered. There was no evidence of monitoring in terms of the outcome of using the medicines we identified concerns with.

Our assessment found the care and treatment people received did not meet the expected standards relating to consent to care and treatment.

There were some systems and practices to ensure that people understood the care and treatment being offered or recommended, for example using an online booking form, however, this information was limited in scope and did not promote the person’s fully informed decision.

The provider did not have risk assessments or policies in place to support a range of decisions relating to consent.

No policy was in place in respect of people who were being continually monitored and recorded by CCTV in the waiting area. There was no signage inside the building to inform patients of the CCTV in communal areas. Patients had not been made aware of this and therefore could not actively withdraw their consent if they wished to do so.

From records we looked at, consent for treatment was not always complete, we saw that there were missing signatures in consultation paperwork. The process for obtaining consent or how staff checked that the necessary paperwork was completed prior to the procedure taking place was unclear.

The service did not record any narrative of how the person had been provided with information in a way that they understood. There were no supporting policies or procedures for obtaining consent to care and treatment.

Staff training records were not available. Staff had not completed chaperone, Mental Capacity Act and Learning Disability and Autistic people Support Training.