Archived: The Sanctum

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 that people were protected from abuse and avoidable harm

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

We assessed a total of 8 quality statements from this key question. Our rating for this key question is inadequate.

We found concerns in all 8 quality statements which included, learning culture, safe systems, pathways and transitions, safeguarding, involving people to manage risks, safe environments, safe and effective staffing, infection prevention and control and medicines optimisation. We found 3 breaches of the legal regulations, specifically, safe care and treatment, staffing, and good governance.

The provider could not demonstrate that they involved people in managing risks.People were not always made aware of potential risks they were being exposed to or given the option to make an informed decision about whether to use the service; there was a poor culture of safety and learning which was not based on openness, transparency and learning from events, which put people and staff at risk of harm. Risks were overlooked or ignored; there was an ineffective approach and a lack of regard for identifying and managing risks to people as they moved between services. There was no collaborative, joined-up approach to safety because information about assessments, treatment and aftercare was not shared with other stakeholders and partner organisations; there was a lack of effective systems, processes and practices to make sure people were protected from abuse and neglect; there were significant safety concerns with the environment; systems were not in place to ensure staff were recruited safely, were appropriately trained and received effective support and supervision and there were significant safety concerns with the management of medicines and treatments.

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 that the care and treatment people received did not meet the expected standards relating to learning culture.

There was a lack of evidence that discussions occurred when things went wrong, or that learning from incidents was embedded at the service. We saw that one event had been recorded, in an accident book, but the details were scant and there was no evidence of team discussion or wider learning to prevent a similar incident from happening again. The process for staff to report incidents, near misses and safety events was not embedded into practice. The provider could not demonstrate that significant events were being dealt with sufficiently. This posed a potential risk for clinical errors to recur because recording, learning, and dissemination of serious events was not undertaken.

The policies, procedures and templates provided to us by the provider on the day of the assessment due for review April 2025. However, they werenot service-specific and did not contain the level of detail we would expect to see in order to provide staff with the guidance to carry out their roles effectively.

There was a poor culture of safety and learning, which was not based on openness, transparency and learning from events. This had put people and staff at risk of harm. Risks were overlooked or ignored, for example, risks related to infection prevention and control and medicines.

We found the care and treatment people received did not meet expected standards relating to safe systems, pathways and transitions.There was an ineffective approach and a lack of regard for identifying and managing risks to people as they moved between services. Safety and continuity of care was not prioritised. There was no collaborative, joined-up approach to safety because information about assessments, treatment and aftercare was not shared with other stakeholders and partner organisations.

The provider told us they had a system for sharing and receiving information from a person’s GP practice for the medical regulated activities. They said they would do this via email or by telephone to the GP practice. However, there was no evidence within patient clinical records that this had happened. There were no records which evidenced the effective and safe receiving or sharing of medical information with stakeholders. The electronic records system did not contain entries to demonstrate patients had been asked to consent to the sharing of their information. There was no evidence that the provider took further steps to explain to people why it was important to share this information with their GP.

We did not receive any feedback from Partners about this service.

There was a policy for safeguarding, but it was not easily accessible to staff. It was held in a paper file in a locked cupboard, and it was not clear whether all staff were aware of the policy. No safeguarding referrals had been made by the service.

Some records we looked at did not include a date of birth of the person using the service, or the record indicated a significantly incorrect date of birth. This meant that care and treatment could not be delivered in a way that met people’s needs and kept them safe. This contravened the need to maintain an accurate, complete, and contemporaneous record in respect of each service user.

There was CCTV in operation in the waiting area, but there was no signage to inform people that this was in operation.

The provider could not evidence that staff had completed safeguarding training as detailed in the Royal College of Nursing Intercollegiate guidance.

There was no system or process for using incidents or complaints to identify potential abuse. This meant the provider could not take preventative action, including escalation where appropriate.

We found the care and treatment people received did not meet the expected standards relating to involving people to manage risks.

There was no effective system to enable the service to identify and assess risks to the health, safety and welfare of people using the service.

People were not always informed about any risks and how to keep themselves safe. Where information was made available to people to view, this was optional and not part of the consent process. Risks were not assessed by the provider. Significant risks in relation to the clinical environment, infection and prevention control, record keeping, and medicines were not communicated to people using the service. This meant they were not aware of potential risks they were being exposed to or did not therefore allow them the option to make an informed decision whether to use the service.

Staff were unsure of their responsibilities in the event of a fire, medical emergency or in relation to infection prevention and control. The medical emergency policy for the service did not correspond with what staff told us would happen in such an event. The staff we spoke with could not recall having practised a fire evacuation.

Staff told us there were 4 clinical rooms used by Sanctum Medical Aesthetics. However, during our inspection we discovered a patient of The Sanctum receiving an intravenous infusion in an upstairs room. This room was not adequately equipped for clinical use. There were no handwashing facilities, no window through which to observe the patient and no emergency buzzer. There was no record kept demonstrating that the patient’s health and condition had been monitored, or any observations recorded during the 2.5 hours they were in that room. Egress in the event of a fire would have been unmanageable due to the patient’s mobility and the disused black bin bags which partially blocked the fire exits.

Fire equipmenthad been checked and maintained in January 2025. We did not see evidence of any fire evacuation drills, or fire safety training within the preceding 12 months, on the day of our inspection.

Items were not stored securely throughout the premises. For example, sharps, medical instruments and medicines used for treatment were accessible via unlocked cupboards. None of the rooms within the clinic were locked when not in use. Fire doors were propped open in some areas. Waste bins were more than two thirds full in the rooms we were given access to, even at the start of clinical sessions. Staff we spoke with could not recall the location of the clinical waste bin store.

Facilities, equipment and technology were in some instances well-maintained, for example, we were told that some equipment had been tested for electrical safety in October 2024. However, there was no register or inventory attached to the electrical safety certificate, so it was not possible to tell which specific items were compliant. We saw some trailing electrical extension leads and cooling fans which were dusty. Staff could not recall if they had been submitted for the electrical safety check. This environment did not consistently support staff to deliver safe and effective care.

There was a lack of overall leadership relating to health and safety. Evidence of the provider’s consideration and oversight to ensure that the premises kept people safe and protected people's privacy and dignity was lacking. Any environmental risks that may have been considered by the provider were not recorded.

Arrangements to manage a medical emergency were not in place. Some emergency medicines were kept for certain procedures; however, no risk assessment had been completed to determine what would be needed. There was no guidance in place to support staff in decision making in the event of a medical emergency.

The service stated they shared the automated external defibrillator (AED) and oxygen with a third-party clinic in the building. However, there was no written agreement between the two services and no checks were completed to ensure that the service which held these items completed necessary checks daily. We spoke with the other service and saw that they had a comprehensive checks process however The Sanctum did not know this was in place.

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

Regular staff meetings with standing agenda items were not taking place. There were no formal mechanisms of communication or discussion about significant events, safety alerts or safeguarding concerns.

Clinical supervision did not take place. The provider confirmed formal clinical supervision or competency assessments were not carried out.

Processes were not in place to ensure the safe recruitment of staff. We reviewed 5 staff files and found gaps in areas of recruitment including appropriate references or equivalent, full employment history and staff immunisations status. There were no recruitment records available for staff who worked in the service, through the renting of rooms or freelancing of services. Recruitment and capability processes were not robust and therefore the provider could not demonstrate that there was no discrimination based on any specific protected equality characteristic.

Where staff were members of a professional body, there was no evidence of registration checks having been done. There was no evidence of tailored induction or competency checks.

Staff did not always receive training appropriate and relevant to their role. A system for ensuring staff were equipped to carry out their role was not in place and was sometimes only apparent when something did not go as planned. The provider told us that they did not have a system for managing staff training and they relied on staff completing mandatory training in their other places of employment.

There was no evidence that clinicians had appropriate indemnity insurance in place.

The premises were not clean during our environmental walk round. There was no schedule, delegation, or oversight of cleaning of clinical areas and clinical equipment between patients’ appointments. This meant that staff and patients could not be assured that clinical areas and equipment were safe from the potential risks of infection.Checklists that were in place contained gaps of several days.

We saw that bins were more than two thirds full at the start of the clinic. This volume of clinical waste was not in line with the provider’s own policy for the removal of waste from bins. Yellow and purple lidded sharps bins were in treatment rooms, and we saw that these were signed and dated and not overfilled.

We observed that clinical staff did not have nails that were kept short, clean or free from artificial products like nail polish. Artificial nails and nail polish can harbour bacteria, interfere with proper hand hygiene, and pose a risk for spreading infection. We observed that clinical staff were wearing jewellery which was not in line with its own ‘bare below the elbow’ approach to its infection prevention and control policy.

There was no liquid hand soap in the wall dispenser of the minor surgery room. There was alcohol gel on the worktop counter, but this would not have provided adequate means for effective hand hygiene during clinical treatments, in particular aseptic techniques.

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.