Private 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

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 safe care and treatment. The service did not have effective processes in place to ensure that clinical fridges used to store vaccinations were maintained within the correct temperature range. The service was using NHS patient group directions (PGD’s) which did not provide a valid legal authority of for staff working in an independent health setting to administer vaccinations.
 

This service scored 56 (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. There was a robust process and policy in place for reporting significant (SE) or learning (LE) events. Staff knew how and when to report incidents which were recorded on part of a purpose-built practice management system which was accessible to all relevant staff. The service maintained a log of events and reviewed it annually to identify any themes. There had been 14 incidents in the year 2025/6. Reports we reviewed had been thoroughly investigated and actions taken in response to the learning points. Feedback was shared individually, via the IT platform and in quarterly clinical meetings so that all staff understood the learning outcomes. There was an open, honest, no-blame approach to investigations and staff we spoke to felt confident in reporting incidents.
The service also learned from complaints, maintaining a log in order to identify any themes or trends. Complaints were investigated and learning shared in the same manner as significant events.
People felt supported to raise concerns and felt staff treated them with compassion and understanding. When things went wrong, staff apologised when appropriate, complied with the duty of candour and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.
 

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider had systems in place to both share and gather information with NHS services when required. Where necessary and with consent, the service shared relevant information with people’s NHS GP. The service actively encouraged people using the service to consider the benefits of this information sharing in order to facilitate smooth transitions of care. The service worked with other providers to deliver shared care and when patients moved between services.
Where the service could not provide certain aspects of care, for example psychological therapies they signposted patients to suitable private or NHS services. There were suitable processes in place to ensure that test results were reviewed and managed safely. A recent audit had identified a significant improvement in the time between the results being received by the clinic and being shared with people from 49.8 hours (November 2025 – January 2026) to 28.4 hours (January – May 2026). However, a small proportion of results were not being shared within this time frame and the service had implemented a key performance target and a digital alert system to improve this.
 

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. We saw evidence that the service shared concerns quickly and appropriately with local authority safeguarding services. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The service had robust policies to follow up people who did not attend appointments (including virtual appointments) particularly where people using their mental health services were involved. Where staff had concerns that patients may be vulnerable or at risk, they were encouraged to offer follow up appointments free of charge, so that cost was not a barrier to ensuring the safety of people using the service. All staff directly employed by the service had appropriate Disclosure and Barring Service (DBS) checks. However, at some sites receptionists employed by the landlord acted as chaperones for Private Medical Clinic staff. There was no system in place for the provider to ensure that these staff had appropriate DBS checks and chaperone training. When we raised this, the provider requested all the relevant documentation from landlords and amended all relevant SLAs to include a system for maintaining oversight in the future.

All staff had training in sepsis and basic life support, 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. There were systems in place to allow patients to access advice and support when required.
However, the provision of emergency equipment varied across locations. At some sites, the equipment was provided by the service and we found some minor omissions which were immediately rectified. At other locations, the emergency equipment was provided by the landlord and formed part of the SLA. At one site where this was the case, we found that some equipment had not been serviced at the required intervals and it was not stored appropriately. For example, the provider had a first-floor clinic room and emergency equipment was stored on the ground floor, in a room where patients were treated and on a wheeled trolley which may delay staff accessing it in an emergency.
The service provided their own emergency medicines and at most locations these were stored in a locked cupboard within the clinic room. The key was kept in a key safe within the same room. This arrangement could delay access to emergency medicines.
At some sites there was inadequate or unclear signage indicating the location of emergency medicines and equipment so that all staff knew where it was when needed.
We raised these concerns with the provider and they took immediate action. An appropriate range of emergency equipment was purchased for all sites, stored appropriately in ‘grab bags’ including tamper evident containers for emergency medicines. Signage was improved where required.
 

All of the sites we inspected were clean, well-maintained and fit for purpose. Each individual clinical room at each satellite clinic was suitably spacious, private and well-equipped. The buildings were accessible and had accessible toilet facilities. Baby changing and breast-feeding facilities were not available at all sites. Clinical equipment had been tested, calibrated and serviced within the required intervals. Fire safety equipment was in place, tested and maintained appropriately. There was a business continuity plan in place which was monitored and reviewed.
Mostly risk assessments were up-to-date, comprehensive and accessible. However, overall oversight and management of risk was incomplete. For example, where risk assessments such as fire and legionella had been completed by the landlord at some locations; the provider did not have adequate oversight or suitable systems in place to follow up the required actions to ensure they had been completed.
There was no Control of Substances Hazardous to Health (COSHH) risk assessment in place at the main location. The provider was unaware that there should be one in place, as they told us that their cleaning contractor brought all cleaning materials with them and they were not stored on the premises. However, we found COSHH materials including paint and white spirit in an unlocked cupboard in a staff area. The provider told us this had been left by contractors working on the site the day before our inspection however, the provider was unaware it had been left. There were no arrangements in place to ensure contractors told staff what hazardous materials they brought into the clinic, they had removed them or that they were stored safely if left on site. The provider’s tenant at this site did have a locked COSHH cupboard but the provider did not have oversight of its contents or their risk assessment.
Building work being undertaken by the landlord at one site had resulted in the main staircase to the service’s first-floor clinic room being closed. Whilst an alternative rear staircase was available this required patients to walk round the exterior of the building to access it. This involved walking along a very narrow paved area along the side of the building which was not designed to be a footpath or across the car park. The potential risk of this building work on people accessing the service on that site had not been recognised or assessed. In addition, there was an upstairs waiting area at this site, which was unmonitored, had no reception staff in attendance, had no CCTV and was not easily viewed by staff working in clinical rooms. This meant that should a patient have a medical emergency and require urgent assistance staff may not be alerted immediately.
We found some minor fire safety issues on several sites such as missing fire action cards at fire exits; fire doors being propped open and excessive amounts of potentially flammable equipment being stored in a basement storage area.
We raised these concerns with the provider during the inspection and they responded immediately with appropriate actions to rectify the issues.
 

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 practice, including consultants, GPs, junior doctors, physician associates and nurses. We found mandatory training was up-to-date and staff were working within their agreed areas of competence. Safe recruitment practices were followed. There was a safe and effective system of clinical supervision in place. The service employed 4 physician associates. These are medically trained healthcare professionals who work alongside doctors to provide patient care under supervision. The service had high-quality processes in place for ongoing review of their scope of practice which was gradually increased as they demonstrated competence and increased their experience. We saw evidence that staff who required role-specific regular training such as those administering vaccines had completed it with the recommended frequency.
However, we identified some gaps in the knowledge and skills of staff responsible for cold-chain management. This deficit had not been recognised when this responsibility had been delegated. No other member of staff or leadership had the requisite knowledge or oversight to identify that the fridge temperature monitoring was being done incorrectly. This indicated that training and competency assessment had not been adequate.
 

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 had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.
 

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. The provider had effective systems to manage and respond to safety alerts and medicine recalls.
However, records we reviewed identified that there were some omissions and inconsistencies in the information gathered by clinicians prior to prescribing and administering travel vaccinations. Staff did not ascertain whether people had received the recommended complement of NHS vaccines, the nature of people’s visit, whether they would be travelling within the country they were visiting and whether they would easily be able to access healthcare. This information is important to ensure that all suitable vaccines are recommended as this may vary by region in some countries and with some high-risk activities, such as some extreme sports. When we raised this with the provider, they implemented a new consultation template which included this information.
Our GP Specialist Advisor noted that the provider’s approach to prescribing weight loss medicines although safe, did not fully align with current NHS weight management guidance. The provider gave assurances that they would continue to review their practice regularly to ensure it remains aligned with current evidence-based guidance.
Healthcare professionals at the service administered travel and flu vaccinations under a patient group directive (PGD). This is a written instruction for the supply and/or administration of a licensed medicine in an identified clinical situation, signed by a doctor which delegates authority to certain healthcare professionals to administer the medicine. However, the service was using NHS PGDs which are not authorised for use by independent healthcare providers. This meant that historically, since opening, those staff administering vaccinations had no legal authority to do so. The provider took immediate action to stop staff administering vaccines under PGD until they had purchased and authorised valid ones.
The provider did not always store medicines in the correct way to ensure their safety and effectiveness. Staff were not correctly monitoring the temperatures of clinical fridges used to store travel and flu vaccines. This was an historical issue occurring between opening the service and June 2026 when the service implemented the use of data loggers which allowed continuous correct monitoring. However, the lack of correct monitoring meant that the service could not be assured that vaccines had consistently been stored within the correct temperature range, which can potentially affect the efficacy of any vaccines administered during this period. When we raised this with the provider, they contacted the relevant authorities and worked with them to undertake a retrospective review and action plan to address these issues. The service also implemented new processes for fridge monitoring and trained all staff to undertake it correctly.