Winnersh

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 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 to safe care and treatment.

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 system to record and investigate complaints and processes for staff to report incidents, near misses and safety events. We found the governance team reviewed this information regularly and used it to drive improvement. We found that lessons learned from incidents and complaints were shared at staff meetings and where appropriate, additional training was provided for staff. Managers told us they encouraged staff to raise concerns when things went wrong. However, some staff told us they did not feel safe to raise concerns or listened to when they did and their concerns weren’t investigated.

The service did not consistently collaborate with patients and healthcare partners to establish and maintain safe systems of care. Managers told us that patients could not have a consultation with a clinician until the service had received a summary care record from the patient’s NHS GP. However, some staff reported that this process was not always followed. While systems were in place to communicate with patients’ NHS GPs, the service did not consistently ensure effective communication between all services involved in a patients’ care. For example, leaders told us that they would not routinely contact other specialist services providing care to the patient, which may result in missed opportunities to coordinate treatment safely.

Safeguarding policies were in place and staff knew how to access them. However, we noted some inconsistencies in how these policies had been adhered to. Designated safeguarding leads were available to escalate concerns promptly and effectively, but the service could not demonstrate how responsibility and accountability for safeguarding was managed outside of administrative hours—such as during evenings and weekends when clinicians were conducting consultations. Following our inspection, the service informed us that they were developing a rota system to address this gap.

All staff we spoke with understood their safeguarding responsibilities and demonstrated a clear awareness of how to report concerns. Staff also told us that they were aware of how to signpost patients to mental health crisis teams. However, the service did not have complete training records to confirm that all staff had completed safeguarding training appropriate to their roles. In the 12 months prior to our inspection, one safeguarding referral had been made by the service. Staff reported that they checked photographic ID, however, we saw from our review of medical records that this was not done at each consultation.Since our assessment the provider has told us they have updated their clinical record template to include a mandatory question to confirm that ID had been checked.

Patients referred themselves to the service via the service’s website and were directed to complete a screening form to identify any obvious contraindications to treatment with cannabis-based products for medicinal use (CBPMs). Staff and leaders told us that patients were informed of risks and safety measures upon acceptance into the clinic. For example, patients were asked to confirm that they would use their medicines as directed, in line with the relevant legislation for cannabis-based products for medicinal use (CBPMs). We saw evidence that patients were advised of potential side effects before starting treatment. However, it was not clear from the records we reviewed that patients were consistently informed that the treatments provided were unlicensed.

We also found that patients were encouraged to choose products from the entire formulary offered by a partnered pharmacy, with no guidance on which types might be most suitable for their condition. These selections were not reviewed by the specialist responsible for the patients’ care. This meant that there was a risk that patients could choose CBPMs that may not meet their unmet clinical need. Clinical staff told us they informed patients about the risk of impairment related to driving or operating heavy machinery. The clinic provided travel letters and advised patients to check the legal status of CBPMs in destination countries before travelling with their prescribed products.

Patients were given advice on risks related to their condition and what actions to take if their condition deteriorated. During hours the service was closed, patients were advised to contact NHS 111 if they experienced side effects requiring urgent assistance. The patient records system included clinical flags to highlight risk and vulnerability, and the service made reasonable adjustments for patients with additional needs—for example, offering longer appointments for those who found communication difficult.

Patients did not physically attend the clinic as the service was offered online-only. Consultations were typically conducted via a secure video platform, and clinicians could switch to telephone calls if connectivity issues arose to ensure continuity of care.

Leaders in the service told us that they monitored demand and used dynamic rotas to make sure there were enough qualified, skilled and experienced staff to meet patient demand. For example, they added more capacity around bank holiday periods. Some staff told us that they found their workload was unmanageable or unsafe in the time allowed. They also told us they weren’t given protected time for some tasks and worked through their breaks. There was a risk that staff would not have enough time to access all relevant information to safely prescribe and undertake any required follow ups with patients and other healthcare professionals, for example, with patients’ GPs. This system placed patients at risk of harm and clinicians at risk of not meeting their requirements of their professional registration.

The service employed a range of clinical staff who were involved in the prescribing processes. There were specialist consultants (doctors included on the GMC specialist register), clinical pharmacist prescribers, and nurses. We saw that all clinical staff completed CBPM-specific training.

Some staff told us they did not always receive effective support, supervision, or development, and teamwork was not always effective in delivering safe, person-centred care. Some staff described situations where they were discouraged from referring patients to more than one specialist doctor, despite the patient having needs across multiple areas of clinical expertise.

Leaders in the service told us they had an onboarding system tailored to staff roles. Some staff told us that they felt supported in their learning and development and described how they had been promoted within the service. However, some staff felt the onboarding process was insufficient. They described having to arrange their own shadowing opportunities, with no additional time allocated for the staff they shadowed to explain processes or answer questions.

When we reviewed training and recruitment records, we found no evidence of training or references for one specialist doctor who had been working clinically in the service for six weeks. However, specialist doctors were working within their agreed areas of competence and safe recruitment practices were generally followed.

The service does not offer face-to-face appointments and operates entirely online. There was an infection prevention and control (IPC) policy in place for the registered location. The IPC policy was aligned with national guidance and updated annually. All staff including clinical staff, undertook infection control training, and there was a designated infection control lead.

People’s medicines were not always prescribed in line with current legislation and relevant best practice. The decision to initiate treatment with CBPMs was made by a doctor listed on the GMC specialist register. Patient cases were not reviewed or ratified by a multidisciplinary team (MDT) comprising of another doctor on the GMC specialist register (specialist consultants) with appropriate skills and experience to effectively determine and ratify unmet clinical need. These decisions were reviewed by a clinical pharmacist prescriber. Furthermore, the ongoing repeat prescribing process did not facilitate specialist oversight for each patient, even when clinically significant changes were made to their treatment.

Staff managed prescription stationery appropriately and securely. Staff involved people in decisions about their medicines and helped them understand how to manage their medicines safely. People were involved with assessments and reviews about managing their medicines safely and to make sure their preferences were included. People were told who to contact if their condition did not improve or they experienced any unexpected symptoms.