Archived: Solutions 4 Health- Newcastle

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 assessment for this newly registered service. This key question has been rated Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of regulations for safeguarding, premises and equipment and staffing.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All staff had access to the service’s electronic reporting system, for reporting incidents. The service had an up-to-date policy on how to report incidents available to staff through the intranet. Staff told us that they reported all incidents in line with the provider’s policy.

Incidents were reviewed by the service manager, feedback from incidents were shared with staff in monthly team meetings. However, staff informed us that learning from across the wider organisation was not shared.

In the 6 months prior to inspection (January 2025 to June 2025) the service had reported 14 incidents through its incident reporting system. Incidents were in relation to the improper notes and or storage of service user documentation and medication errors. Staff informed us that following the incident around medication storage, changes were made to ensure similar medications with at different concentrations were stored separately.

The service had an up-to-date duty of candour policy available to all staff.

The service did not have access to all service users’ sexual health treatment history, therefore when a service user visited the service for the first time a full sexual health history needed to be taken.

The service was not able to refer service uses for scans, additional tests or x-rays. Service users were referred to their GP for these to be facilitated.

The service was experiencing delays in receiving test results from a third-party testing facility, along with incorrect results. Staff informed us this was leading to delays in treatment and therefore they believed the service was not adhering to national standards.

Staff we spoke to were able to identify adults and children at risk of or suffering significant harm. Staff at the service received instructor lead level 3 safeguarding training and the compliance for this at the time of inspection was 64%. However, we were not provided with the contents of this training and therefore cannot be assured that the training covers the requirements for safeguarding adults and children.

The service had not notified CQC regarding safeguarding referrals as required. The service is required to inform CQC about abuse or allegations of abuse concerning a person using their service if the person is affected by abuse, they are affected by alleged abuse, the person is an abuser, or they are an alleged abuser. In the 6 months prior to inspection the service reported 9 safeguarding incidents to the local authority from January 2025 to July 2025, these incidents had not been notified to CQC.

The service informed us all staff at the service should have received level 3 adults and children’s safeguarding training.

Staff at the service was level 1 and 2 training and level 3 where applicable. Staff who consult with clients either directly or indirectly should be adequately trained in safeguarding adults and children. Any staff involved indirect clinical contact, including telephone consultations should be level 3 trained. Managers at the service indicated that Band 7 and 8s at the service were level 3 trained and the point of escalation for staff. Intercollegiate guidance states that staff providing expert advice and contributing to the development of safeguarding policies and procedures should be trained to level 4 or 5.

It was not clear who had the overall responsibility for safeguarding at a board level. The safeguarding lead identified to us, by the leadership team, was a contractor and did not work for the service full time. Staff informed us they struggled to contact the lead for safeguarding.

The service did not provide evidence that they engaged in any local safeguarding panels.

The service was not always able to comprehensibly manage service user risk. The service did not have access to service users’ previous sexual health records. The staff reported they had difficulties accessing previous sexual health records, this delay put patients at risk of under or over treating.

We found 11 service user records had no documentation of medical history, allergies, lifestyle review or safeguarding assessment in the records.

The service did not detect and control potential risks in the care environment. They did not ensure equipment, facilities and technology supported the delivery of safe care.

The facilities were not well designed for the client group. The toilet available for service users was accessed through the sluice, an area that should not be accessible to the public as there was access to medical supplies and cleaning chemicals in this area.

Staff informed us the walls of the service were too thin to allow privacy and dignity so the radio would be put on in reception to mask people’s conversations. Our own observations of the service confirmed this.

Staff only had access to a hand held alarm in each room to raise the alarm for their and their service user’s safety. We asked the service for an audit of the alarms; they informed us they do not perform audits or tests on the alarms. Therefore, there were no assurances this was an effective and safe way to protect people from harm.

Staff did not have easy access to a phone to call emergency services. The service’s phone system was computer based. Meaning if staff needed to call emergency services they were required to log into their computer as well as using a headset. One staff member informed us they were unable to dial emergency services from the phones, they had not been informed by the service this had been updated.

The service only had access to 2 plumbed in sinks – one in the sluice and one in the laboratory. The rest of the sinks in the examination rooms were portable sinks. Staff informed us they needed to empty and fill up these sinks each morning. Staff told us the temperature could vary on these sinks, the service did not regularly carry out check on the temperatures.

The service did not have any signage to indicate where the oxygen in the service was located. It is a legal requirement for a service to have appropriate signage to indicate the presence of oxygen, associated hazards, and include prohibition signs (e.g., no smoking, no naked flames) and emergency contact details.

The service did not have appropriate signage to indicate the presence and location of Automated External Defibrillator (AED), so the staff and general public know the location in an emergency. This is also considered necessary by the National Resus Council.

The service did not always make sure there were enough qualified, skilled and experienced staff. For example, we noted that consultant cover was not in line with national guidance. Leaders told us arrangements were in place to cover this gap using suitably skilled and qualified staff who were not trained to consultant level. Staff told us they did not feel this arrangement was satisfactory and was not in line with national guidance.

Staff at the service did not meet the mandatory training required for the role. Mandatory training for staff was at 86.6% for all staff at the service. However, there were modules of mandatory training that had a low compliance rate, these were paediatric resuscitation level 2 at 60%, instructor led venepuncture/phlebotomy at 53% and sexual and reproductive healthcare at 10%.

The mandatory training figures for infection, prevention and control (IPC) were 0%. 88% of staff did complete hand hygiene training.

Staff informed us they had raised multiple concerns regarding the IPC of the service. The service commissioned an external review of their IPC of the environment in December 2024.

We found areas of this external report had not been addressed by the service at the time of inspection. For example, damaged examination couches still in use and Hibiscrub being left in patient accessible areas. The action plan following this report did not address the immediate concerns. At the time of the reports and our inspection the service was planning to move to a new building, which they believed would rectify these issues. However, we were not assured that the current premises were IPC compliant.

The service carried out ‘daily sink checks’, however it is unclear from documentation what was being assessed. Daily environmental checks of the clinic room bins were undertaken by staff. The service had a schedule of cleaning tasks that should be carried out daily, weekly and monthly. However, we found that the weekly checklists were not consistently completed. Therefore, the service could not evidence they were complaint with their own policies and procedures.

We found that new swabs and pots for chlamydia and gonorrhoea testing were being stored under the staining sink in open boxes, leaving them open to contamination.

Medicines at the service were overseen by a nurse lead. There was no oversight from a pharmacist at the service. However, there was a pharmacist representation on the Solutions 4 Health Medical advisory board. Staff we spoke to were not aware of this.

We were informed by management that there were standard operating procedures (SOPs) for medicines management. Staff told us they were not aware of these SOPs prior to the CQC inspection. We found the SOPs were not in date, as per the service’s review date, and informed by staff that they were not an accurate representation of the processes in place.

Staff raised that the service did not stock the relevant medication for some service users, in these cases, the service user was referred to their GP. The provider told us that only on rare occasions were they not able to issue medications.