Archived: Fitzrovia 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

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

The service was in breach of legal regulations in relation to safe care and treatment and good governance.

This service scored 34 (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 did not always have a proactive and positive culture of safety, based on openness and honesty.

Managers encouraged staff to raise concerns when things went wrong, and staff felt there was an open culture. However, we reviewed a sample of meeting minutes and found these lacked sufficient detail to demonstrate learning from incidents, concerns and feedback was consistently discussed and shared. Staff had completed accident and incident reporting training and were able to describe the process for escalating concerns and reporting incidents internally.

The service did not 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. They did not always make sure there was continuity of care, including when people moved between different services.

We were not assured there was an effective system in place to ensure appropriate follow-up of abnormal test results and referrals. We reviewed a sample of 5 patient records and identified an example where a patient aged over 70 had a raised prostate-specific antigen (PSA) result, suggestive of potential malignancy, and did not have a documented follow-up consultation regarding these abnormal results. The service told us following our site visit that a follow-up consultation, informing the patient of the results, had taken place. We were not provided with evidence of this appointment. We did not see evidence of any referral to secondary care for this patient. The service told us that this patient was an overseas patient. For the 4 other patient records we reviewed, appropriate follow-up arrangements were in place. We did not see any evidence of patients receiving results and we did not see that the service had a failsafe policy or system in place regarding the follow-up of abnormal test results. The absence of an effective system to ensure follow-up of abnormal results could expose patients to risk of avoidable harm, as they may not receive timely and appropriate care.

There was a system for appointment triage where patient requests were received by telephone and email. Non-clinical staff were involved in triaging appointment requests, however, we did not see any evidence of completion of specific care navigation training by these staff members. Where clinical concerns were identified, staff told us they would refer concerns to the lead GP or seek support from the wider Fitzrovia Hospital team if the lead GP was unavailable.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately. We reviewed recruitment records and saw Disclosure and Barring Service (DBS) checks and certificates in place for staff. Safeguarding policies were in place and staff knew how to access these. However, during our interviews, a member of staff was unable to identify a safeguarding concern or describe the appropriate escalation procedures demonstrating a lack of knowledge. The service had no instances of safeguarding referrals or cases. The majority of staff had completed appropriate safeguarding training, however, for one member of clinical staff we did not see evidence of completed training for safeguarding children.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During our on-site assessment, we found that the service did not have effective systems in place to ensure that appropriate emergency medicines and equipment were available, monitored and had not expired or that risks had been assessed where items were not held on site. We were informed that the clinic had an arrangement with Fitzrovia Hospital to access its emergency medicines and equipment, which were held in a grab bag in the reception area. We reviewed the emergency equipment available and found recommended equipment were missing, which was not consistent with Resuscitation Council UK guidance. We found the service did not have a safe system for dealing with emergencies and it did not have immediate access to the minimum suggested resuscitation equipment to provide appropriate personal protective equipment. There were no documented risk assessments to support why this minimum suggested resuscitation equipment was not held or actions staff should take to mitigate risks. We found that the service could not demonstrate it had a safe system for dealing with emergencies as it did not have immediate access to additional suggested resuscitation equipment. We found items missing from the emergency supplies, including portable suction equipment and clear face masks. These items are used in emergencies to help keep a patient’s airway open and support breathing. There were no risk assessments to demonstrate why this equipment was not held or actions staff should take to mitigate risks. Staff we spoke with during our interviews were unable to demonstrate an understanding of sepsis and appropriate escalation procedures, despite training records showing this had been completed recently.

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. Contracts were in place to ensure the premises were maintained. The service was accessible and had a ramp for patients with mobility issues. The clinic displayed information for patients relating to chaperones and complaints. The provider had a fire policy, fire alarm testing logs were completed and a fire risk assessment had been undertaken. The provider also had legionella risk assessments and regular legionella and portable appliance testing (PAT) testing in place. However, the clinic could not demonstrate it operated a safe system to check and replace medical equipment and supplies as we found examples of expired equipment and supplies. We found items which were out of date in the emergency grab bag including glucose 10% liquid pouch, used to treat critically low blood sugar levels, which expired in February 2025, disposable gloves for infection prevention and control (IPC) which expired in October 2023 and a supraglottic airway device, used to help maintain a patient’s airway during emergency resuscitation, which expired in May 2025. We also found that the clinic was missing a thermometer. The provider had told us that clinic would ensure that this was replaced following our assessment.

The service did not have effective systems in place to make sure there were enough qualified, skilled and experienced staff. The clinic employed two members of clinical staff and two members of non-clinical staff. The service did not have effective systems in place to manage staff training and recruitment files. We reviewed recruitment and training records for all members of staff and found these were incomplete during our on-site assessment. Following the assessment, additional documentation was submitted, however, we still found gaps in records. We did not see evidence of professional registration for one member of clinical staff. We were not assured staff had appropriate immunisations as one record was provided in a language other than English with no evidence it had been translated or verified by the provider. For another member of staff, a record of immunisation had been provided in the form of a summary document which did not provide us with sufficient assurances that appropriate immunisations had been completed in line with the UK Health Security Agency Immunisation of Healthcare and Laboratory Staff guidance. For one clinical member of staff, there was no evidence of completed training in fire safety, safeguarding children, sepsis, manual handling, chaperone training and learning disability and autism awareness. We also did not see evidence of chaperone training being completed for the lead GP.

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.

The clinic was visibly clean and there was appropriate hand hygiene signage. Cleaning arrangements were supported through a service level agreement and weekly cleaning schedules were in place and followed. Staff had relevant infection prevention and control (IPC) training. However, the clinics IPC audit was limited in scope and focused only on personal protective equipment (PPE) and hand hygiene. The audit lacked sufficient detail around the processes used with limited comments on the results and further action planning. We observed two chairs in the clinic which were fabric and not wipeable to allow cleaning between patients.

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

The provider told us the clinic primarily prescribed medicines for acute conditions and did not routinely prescribe controlled drugs or specialist medicines.

We found the service did not have effective systems in place to ensure that appropriate emergency medicines and equipment were available, monitored and had not expired or that risks had been assessed where items were not held on site. During our site visit, we reviewed emergency medicines available in a grab bag in the reception area and found that 6 of the suggested emergency medicines were not available in line with the Resuscitation Council UK guidelines. These included antiemetics (for nausea and vomiting), benzylpenicillin (for suspected bacterial meningitis), dexamethasone (for croup in children), diclofenac (for analgesia), glucogel (for hypoglycaemia) and midazolam (buccal) or diazepam (rectal) (for the management of seizures). There were no documented risk assessments to explain why these medicines were not held on site or what mitigating actions staff should take. Following our on-site assessment, the provider told us that provision of emergency medicines were supported through the wider Fitzrovia Hospital and located in other areas of the hospital. These arrangements were not clearly communicated to us during our on-site assessment. We were not assured that the provider demonstrated sufficient awareness of the arrangements for access to emergency medicines and equipment. Staff told us weekly checks of the emergency grab bag were undertaken by the clinic, however, we did not see documented evidence to confirm these checks had been completed. During our review of the emergency grab bag, we found that the oxygen cylinder displayed a reading of 0 oxygen despite records indicating that checks had been completed and the cylinder was 3/4 full. Following our on-site assessment, we received a response from Fitzrovia Hospital stating the oxygen cylinder had been replaced on the day of our on-site assessment and providing an explanation as to how the cylinder operates. The provider did not demonstrate awareness of this or provide assurances that appropriate action had been taken when we raised this during our on-site assessment.