90 Sloane Street Limited

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.

At our last inspection in July 2018, we rated this key question as Good. At this assessment in March 2026, the rating remains the same.

This service scored 63 (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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. The service encouraged staff to raise concerns when things went wrong.

We found that safety was a top priority and the provider had processes in place to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents resulted in changes that improved care for others. For example, the service informed us of an incident where a patient was administered a vaccine which was later found to be unnecessary, as the patient had already completed the required two-dose course. The incident was documented and shared with the team to reinforce the importance of checking vaccination histories before administering vaccines.

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.

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 and procedures were in place. Staff had received appropriate safeguarding training and were able to describe the procedures to follow if they had safeguarding concerns. The service provided treatments to both children and adults. Systems were in place to verify patients’ identities. Where children attended the service, processes were in place to ensure that any accompanying adult had appropriate parental responsibility.

A risk register was maintained for vulnerable patients and was reviewed regularly. However, individual patients were not always coded in the operating system, despite the availability of a dedicated coding system.

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.

The staff were suitably trained in emergency procedures. Emergency medicines and emergency equipment were checked regularly. However, emergency medicines were stored in three locations: the crash trolley, individual consulting rooms, and a locked cupboard. While the service had all recommended emergency medicines on the premises, those stored in the locked cupboard may not be readily accessible in an emergency situation. The service operated across four floors and was required to review this arrangement to ensure that the crash trolley is fully always stocked with all recommended emergency medicines. We found that paediatric pads for the defibrillator were not in stock, and a paediatric pulse oximeter was not available. Following the inspection, the service provided evidence that both items had been obtained and were available for use. Oxygen cylinders were checked annually.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The provider gave patients after-care information once treatment had been given and ensured the patient knew who to contact if there were any concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. A health and safety risk assessment was not available on the day of the inspection. The service subsequently provided a copy of the assessment, which had been completed on 31 March 2026, a few days after the inspection. The service was required to develop and implement an action plan to address the risks identified within the health and safety risk assessment.

The fire risk assessment was carried out by an external contractor in March 2026. The fire system was inspected regularly; the fire extinguishers were checked and there was a record of fire alarm checks. The service carried out regular fire drills.

Calibration of medical equipment and portable appliance testing (PAT) was carried out.

A gas safety check was carried out in March 2026.

The service was unable to provide Electrical Installation Condition report (EICR) for the registered address.

The service was unable to provide evidence of a formal documented legionella risk assessment on the day of the inspection. Records of water temperature monitoring and water flushing were also not available. We saw that water analysis testing had been carried out on 5 August 2025. The service subsequently provided a copy of a legionella risk assessment, which had been completed on 31 March 2026, a few days after the inspection. The service was required to develop and implement an action plan to address the risks identified within the legionella risk assessment.

There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the service. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

Recruitment checks were not always carried out in accordance with regulations prior to employment. For example, the 4 staff files we reviewed showed that references (satisfactory evidence of conduct in previous employment) had not been undertaken prior to employment for 2 staff. Interview notes were not kept in all 4 staff files. Appropriate health checks (satisfactory information about any physical or mental health conditions) had not been undertaken prior to employment for all 4 staff members.

All staff had received Disclosure and Barring Service (DBS) checks appropriate to their role.

We found staff training was up to date and learning needs of staff was managed appropriately, and staff were working within their agreed areas of competence.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The environment was noted to be clean and tidy during our onsite visit, and all appropriate personal protective equipment was available for staff to use.

Feedback from people who use the service, was positive in relation to the cleanliness of the environment.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

We reviewed 12 clinical records, which were stored electronically on a secure network. Records were complete, accurate and up to date. Consultation notes demonstrated appropriate clinical decision-making. Staff followed established prescribing protocols and ensured medicines were prescribed safely. People knew what to do and who to contact if they experienced any unexpected symptoms.

The service kept stocks of medicines such as antibiotics and painkillers, which it dispensed to patients. There was an effective system for monitoring and managing these medicines, which kept patients safe.

Staff regularly checked the stock levels and expiry dates for emergency medicines.

Fridge temperatures were monitored regularly, and records were well maintained. However, at the time of inspection, the fridges did not have a secondary thermometer installed, and 'Do Not Remove' stickers were not displayed adjacent to the fridge sockets. Following the inspection, the service provided evidence that a secondary thermometer had been installed and 'Do Not Remove' stickers had been placed next to the relevant fridge sockets.

The service stored medical gases, such as oxygen, safely and completed the required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls. Safety alerts were received by a dedicated person and managed effectively. However, a log was not maintained.