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The Wells Clinic at Robert Denholm House Requires improvement

This service was previously registered at a different address - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 24 October 2019

Inspection areas



Updated 24 October 2019

  • Appropriate recruitment checks had not been always undertaken prior to employment.
  • Appropriate risk assessments had not always been undertaken.
  • Not all members of staff, that had contact with patients, were in possession of a Disclosure and Barring Service (DBS) certificate and no risk assessment had been undertaken around this area.
  • There were no effective processes in place to verify the identity of patients or those accompanying children.
  • Emergency medicine checks were not always sufficient to ensure appropriate medicines were held.

Safety systems and processes

The service did not have clear systems to keep people safe and safeguarded from abuse.

  • The provider had not conducted, or assured themselves of, safety risk assessments. The service provided a health and safety handbook following the inspection which contained policies but only a fire risk assessment was seen. This had been partially acted upon however, by rectifying one issue, the provision of a ramp, a separate trip hazard had been created and not addressed. Evidence was sent following the inspection that this had been remedied. The provider did
  • The service had systems to safeguard children and vulnerable adults from abuse, however, only the GP had undertaken safeguarding training for adults. The receptionist had undergone child safeguarding training to level two and the GP to level three. There were no fire evacuation procedure signs within the building to enable people to congregate at the correct rendezvous point. The fire risk assessment stated that names would be checked off against a visitor’s book, held centrally at reception, in the event of a fire but the inspection team had not been asked to sign in on arrival.
  • The service did not have sufficient systems in place to assure that an adult accompanying a child had parental authority. The service made a verbal check, but no ID checks were undertaken.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider had not fully carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. References were not on file for a current non-clinical employee. Following the inspection, the service forwarded information for the currently employed person. Disclosure and Barring Service (DBS) checks were not always undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). There was no DBS check for the receptionist and no risk assessment had been undertaken in relation to this. The provider did undertake a proof of identity check prior to employment.

  • Not all staff received up-to-date safeguarding and safety training appropriate to their role, as no evidence was shown to evidence adult safeguarding for the receptionist. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was not an effective system to manage infection prevention and control. There was a Legionella policy and procedure but no actual assessment had been undertaken, nor had the provider received assurance that it had been undertaken by the owners of the building. During the inspection it was seen that a sharps bin was within reach of children. Hand washing solutions were also seen to be stored in the sink and not wall mounted. Information was sent following the inspection to show that the issues relating to the sharps bin and hand washing solutions were remedied.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider had not carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who might be accompanying them. A premises risk assessment was requested at inspection for this area of concern, but no actual risk assessment was provided, this risk assessment might have enabled the provider to recognise areas of risk and potential harm to those visiting or working at the clinic. Following the inspection a premises risk assessment, dated January 2018, was supplied which did not document that issues found requiring attention during that audit had been resolved. An online training certificate for fire safety training was also sent following the inspection, dated September 2019, which was not available at the time of inspection.

Risks to patients

There were not systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an induction system for agency staff tailored to their role.
  • Not all staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. Staff had some training in recognising serious issues, but training had not been undertaken for sepsis awareness by reception staff.
  • The building had a shared defibrillator which on the day of inspection was difficult to access due to its location and the condition of the room where it was stored. There was not a documented check kept of its operability, such as the battery working, within its unlocked case.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service did not have reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment to minimise risks, however, these were not always sufficient. The service undertook medicine checks and kept a list of medicines required. The service kept prescription stationery securely and monitored its use. It was seen on the day of inspection that there was one out of date medicine within the emergency medicines store which was removed. Two medicines were also absent, glucagon and hydrocortisone, with no risk assessment in place for these not being present, but evidence was sent following the inspection that the medicines had been obtained. Information was sent following the inspection that sugary sweets could be used for some diabetic emergencies instead of glucagon, but these were also not present within the emergency medicines on the day of inspection either.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered medicines or vaccines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety and incidents

The service did not have a good safety record.

  • There were not comprehensive risk assessments in relation to safety issues. No premises safety assessment had been evidenced during the inspection however one was sent following this that was dated January 2018 but did not evidence that issues that had been identified within this had been remedied.
  • The service monitored and reviewed activity. This helped it to understand some risks and gave a clear, accurate and current picture that led to some safety improvements. On the day of inspection, the clinic room did not have a warning sign that oxygen was within the room to alert anyone should a fire happen. However, following inspection evidence was sent showing that this had been rectified.

Lessons learned, and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, and shared lessons identified themes and took action to improve safety in the service. For example, one vaccine package had been left out overnight following delivery, so all affected vaccines were discarded immediately. A discussion was then held on the importance of the cold chain.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts.


Requires improvement

Updated 24 October 2019

  • Staff had not been trained appropriately for their roles, for example, training was overdue for cervical screening for the GP and sepsis awareness for the receptionist.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service). However, there were some gaps in this area.

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence evidence based guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing. Discussions were had with patients receiving yellow fever vaccines, but it was not always documented that the risks associated with this process had been discussed.
  • Consent forms were not always fully documented. We checked two chicken pox immunisations for children and one was not fully completed.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat prescriptions.
  • Staff assessed and managed patients’ pain where appropriate.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.
  • The clinic offered child, adult and travel immunisations.
  • When a patient needed referring for further examination, tests or treatments they were directed to an appropriate service.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits, for example, antibiotic prescribing. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.

Effective staffing

Staff did not have all the skills, knowledge and experience to carry out their roles.

  • All staff had undertaken some training. The provider had an induction programme for all newly appointed staff. We saw evidence of child safeguarding for the receptionist, that was sent following the inspection, but no adult safeguarding training certificate was provided. The receptionist had undertaken some training within her other work role, at a different provider, but no training had been undertaken for areas such as sepsis awareness or fire safety.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) and were up to date with revalidation.
  • The provider understood some of the learning needs of staff and provided protected time and training to meet them. However, during our inspection we found that the GP had not undergone cervical screening training within the previous five years which was outside the requirements of three yearly training.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked well with other organisations, to deliver effective care and treatment.

  • Referrals to secondary care could be made on the same day as the GP consultation.
  • Referrals were made in a timely manner and the patient was always given the option of a referral in to either private or NHS services.
  • Clinical staff were aware of their responsibilities to share information under specific circumstances (where the patient or other people are at risk) and explained other circumstances when they would work to get consent to share information, by explaining the risks to the patients if they did not.
  • When information was received into the service it was reviewed by the GP and then scanned onto the patients records. Where patients had given consent, the clinician wrote to the patients’ NHS GP to inform them of treatment the patient had received.
  • Clinical staff were appropriately trained so that they are fully aware of their personal responsibilities in respect of record keeping and records management.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice, so they could self-care.
  • The service supported patients to live healthier lives by providing same day GP access for patients. These patients were able to access a GP, receive a diagnosis and medication where required.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service did not always obtain consent to care and treatment in line with legislation and guidance


  • Staff understood the requirements of legislation and guidance when considering consent and decision making, however consent obtained was not always recorded appropriately.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • It was seen on the day of inspection that consent had not always been fully documented. This was seen on a child’s chicken pox vaccination and also that risks surrounding the yellow fever vaccine had not been documented as discussed within a patient’s notes.



Updated 24 October 2019

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • Thirteen patients provided feedback about the service via comment cards. All of which was positive about the standard of care they received. The service was described as excellent, professional, helpful and friendly.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. We were told that this need would have to be identified prior to the appointment as the clinic would need to make specific arrangements to accommodate this.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • The service ensured that patients were provided with all the information, including costs, they required to make decisions about their treatment prior to treatment commencing.
  • Any referrals to other services, including to their own GP, were discussed with patients and their consent was sought to refer them on.
  • Staff had received training in equality and diversity.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • There were screens in the consultation room for patients to change behind prior to examinations or treatment.
  • Assessment room doors were closed, and we noted that conversations taking place could not be overheard.
  • All confidential information was stored on a secure cloud platform.



Updated 24 October 2019

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The service was designed to provide easy access to GP appointments and to various different types of skin treatment, at times convenient for patients.
  • The provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.
  • The provider understood the needs of its patients and tailored services in response to those needs, for example the clinic had a ramp placed within the building to allow access to the consulting room for those in a wheelchair. However, this ramp had become a trip hazard. The clinic was on the ground floor and doorways were wide enough to allow wheelchair access.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Same day appointments were available depending on demand.
  • Patients could book by telephone or e-mail.
  • Longer appointments were available when patients needed them.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way.
  • Bookings and enquiries were open Monday to Friday 8am to 6pm. Clinics were run Tuesdays and Thursdays 8am- 4.30pm and one Saturday in every four between 9am - 12pm. However, there was a degree of flexibility to suit patients’ lives and consultations would be scheduled on a case-by-case basis.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.


Requires improvement

Updated 24 October 2019

There was a lack of good governance to ensure effective monitoring and assessment of risks to patients. There was not sufficient recruitment checks and gaps in staff training were not always monitored appropriately.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The aims and objectives were set out clearly in the clinic’s statement of purpose.
  • The service monitored progress against delivery of the strategy.
  • The clinic had a vision of providing high quality, holistic, primary medical care complementary to the care available to patients on the NHS.


The service had a culture of high-quality sustainable care.

  • The service focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • They had not established proper policies, procedures and or taken appropriate action to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were was no clarity around processes for managing risks, issues and performance.

  • There was not an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety. There were areas of risk management undertaken by the owners of the building that the provider had not assured themselves were satisfactory. For example, a Legionella risk assessment with detailed assurances from the premises owner in relation to storage tanks or fire evacuation notices.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • The service used performance information which was reported and monitored and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.
  • Where patients had consented, the patients’ NHS GPs was informed of treatment received, referral letters were timely and detailed. There was a system to ensure results were dealt with appropriately.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The provider encouraged and valued feedback from patients and staff. Any feedback was monitored, and action was taken if this indicated that the quality of the service could be improved. There was numerous ways to leave feedback, through their Facebook page, Google business reviews and personally.
  • There were 13 CQC patient comment cards. All the cards were positive about the service they had received.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • The GP maintained strong links with colleagues in the NHS. They continued to work part-time in NHS roles as well as working at the clinic. This allowed them to share best practice and improve services.
  • The service was relatively new, and the provider was reflective and keen to improve the quality and range of services available.