Archived: Enterprise Health Care

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 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.

There was no effective system to support a culture of learning or improvement. Safety incidents were not accurately recorded or reviewed to drive learning or improve safety. At least three incidents had occurred over the last two years but only one was recognised or reviewed by the provider. We reviewed details of that incident and saw related documentation was inconsistent, lacked effective root‑cause analysis, and a linked complaint was not integrated into learning. Complaints trends, including ten involving the same clinician were not analysed to consider improvements.

Not all systems to ensure safe pathways and transitions of care were in place or effective.

Arrangements for receiving patients’ test results and making referrals were in place. However, the patient registration process did not request, or record patients’ consent to share information with their GP. There was also no system to review patient’s consent considerations during care and ensure that important clinical findings, such as an abnormal test result could be shared with their GP. This created a risk that patient’s abnormal results might not receive appropriate clinical follow‑up or management.

Safeguarding arrangements were not effective.

Three of four consultants had no safeguarding adults or children training recorded, and the safeguarding lead GP had no evidence of safeguarding training. Safeguarding policies were out of date and contained incorrect guidance, including obsolete escalation routes and outdated statutory references.Staff were not supported with reliable or current safeguarding processes, increasing the risk that concerns could be missed or mishandled. Staff told us that there had not been any safeguarding concerns.

The service did not work effectively with people to understand and manage risks.

The only audit of patient outcomes to ensure safe services that had been completed was an audit of post‑procedure infection rates. This audit was ineffective because it lacked sufficient detail and contained inconsistencies within the underlying data. The information could not be reproduced or validated, and no actions had been taken to look into or improve the post procedure infection rates audit or to undertake a re‑audit. As a result, potential risks were not identified and there was no learning to reduce risks over time.

Arrangements in place for responding to a medical emergency were ineffective. Several emergency items had expired, including the paediatric oxygen mask (expired August 2025) and multiple oropharyngeal airways (expired in 2023).

We found no evidence of basic life support (BLS) training for three of the four consultants or for the lead doctor. There was also no risk assessment or rota planning to ensure that staff with appropriate BLS training were on‑site, in the event that an adult or child required life support.

Patients received post procedure after care leaflets, they were advised on risks related to their condition and actions to take if their condition deteriorated.

The provider had introduced a mobile‑phone–based system for staff to check whether medical items were fit for use. However, we found multiple medical items in treatment rooms and storerooms that were expired and not suitable for use, with some dating back to 2022. These included syringes, surgical items, clinical sample kits, venepuncture sets, microsurgical knives, skin closures, and biopsy punches. We then reviewed the mobile‑phone system that staff were expected to use and found that expiry dates were not recorded. This meant the system could not be used to identify or prevent expired items from remaining in circulation.

We reviewed 19 patient records covering the range of services provided and found no evidence of inappropriate prescribing or of patient harm.

There were no effective arrangements to ensure environmental safety.

The provider did not ensure safe recruitment processes or that staff had the qualifications, training, or competence necessary to deliver safe care. Checks of clinicians’ qualifications, GMC registration, revalidation, and specialist skills were incomplete or absent for most consultants.

There were no effective arrangements to ensure Infection prevention and control (IPC).

Surgical instruments were stored without dates, so sterility could not be assured. Surgical instrument decontamination was unsafe because the autoclave (used to sterilise reusable surgical instruments) was in an unsuitable staff kitchen area without a proper dirty‑to‑clean workflow, where we also found multiple mouse traps or bait stations on the floor and on a window ledge behind the sink that was visibly dusty.

Cleaning systems were ineffective. There were no cleaning schedules or audits for the premises, fixtures, fittings or equipment and the ultrasound machine was visibly soiled. The colour‑coding of cleaning equipment was unclear and a spillage kit (intended for cleaning spillages of bodily fluids) had expired in 2022.

The IPC clinical lead GP and staff involved in clinical procedures had not received appropriate IPC training, or any IPC training. The IPC audit, undertaken by the untrained clinical lead GP was out of date and incomplete. It lacked reference to guidance and improvement actions identified had not been followed up.

The provider immediately implemented improvements and provided us with an urgent action in response to our feedback.

Medicines were not always managed safely.

Emergency medicines had not been checked since May 2025. The provider did not stock injectable chlorphenamine, which is required for treating an acute allergic reaction, but other medicines needed in line with services provided were stocked and had not expired.

The medical refrigerator had only a single thermometer and did not display a ‘do not switch off’ sign, meaning the provider could not be assured that temperature sensitive medicines were stored safely or consistently within the correct temperature range.

The provider had a mobile-based system intended to check medicine stocks and expiry dates. However, the system did not record expiry dates and had not been used. We found various opened and part‑used creams and ointments stored in a treatment room intended for use on multiple patients, with no system in place to ensure they remained safe for use.

Prescriptions were generated electronically; however, there was no prescribing audit for any medicines, including antibiotics and no oversight of clinical decision‑making, including for high‑risk medicines such as methotrexate and cyclosporin (medicines used to treat autoimmune/immune‑mediated conditions including psoriasis). This meant the provider could not be assured that prescribing was optimised in line with expected clinical standards.

The provider immediately began making improvements and sent us an audit of patients prescribed high-risk medicines in response to our feedback, to ensure safety.