Treat It Clinic

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Medicines optimisation

This key question has been rated as requires improvement. The service was in breach of legal regulation in relation to safe care and treatment.

We found the service had policies and processes for safeguarding, managing incidents, recording decisions about prescribing, and working with partners. However, there were gaps in some policies and processes, and they were not robust. For example, gaps in the processes used to confirm a patient’s identity, the recording of multidisciplinary meeting outcomes and a lack of consistency in liaising with patients’ NHS GP. The provider had taken action to mitigate these risks, but it was too soon to check the changes were fully embedded in the service.

This service scored 61 (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 and safety events.

The service did not consistently collaborate with healthcare partners in line with the General Medical Council (GMC) good prescribing guidance. The service did liaise with some partners and ensured that they had access to relevant medical history before prescribing. However, it is essential staff liaise with patients’ NHS GPs before and during treatment to ensure an accurate and up to date view of care for prescribing high-risk medicines. This includes informing GPs of significant changes to prescriptions such as strength and dosage of medicine. We saw when reviewing patient records that this was not routinely done. We did not see a process for when to update GPs of significant changes to prescriptions and this was open to staff subjectivity. The provider told us that the issue with sending information to GPs was due to inconsistent administration, and this had now been reviewed and improved. However, it was too soon to measure if the new systems had been effective.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

However, identity checks were not always recorded, and proof of identity was missing in 2 of the 6 records reviewed, which did not meet the service’s prescribing policy. Although software was used to verify identity at sign‑up, ongoing checks were inconsistently documented, posing a risk of high‑risk medicines being prescribed inappropriately. This did not ensure that patients were safeguarded against improper use of medicines.

The service worked with patients and together as a clinical team to understand and manage risks by thinking holistically about patients. Patients were given advice on risks related to their condition.

The service was provided online for patients with staff working from an office location. The service had reviewed potential risks in the office environment for staff such as fire and health and safety.

The service was only provided to UK patients, but the call centre for the service was abroad. Risks relating to using a call centre outside of the UK had been mitigated by contracting an external organisation to complete an assessment for data protection in line with the General Data Protection Regulation (GDPR).

There was a business continuity plan in place which was monitored and reviewed.

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 a nurse. We saw that clinical staff completed training on cannabis-based products for medicinal use (CBPM). Recruitment checks were carried out in accordance with regulations.

People’s medicines were 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 reviewed and 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. Staff managed prescription stationery appropriately and securely.

However, patients were immediately moved onto the care of the non-specialist prescriber after the first prescription which was not in line with best practice. There was a risk that the effectiveness of the medicines would not be appropriately or safely determined without specialist input. This risk was mitigated since all patients were reviewed after 6 months treatment at the MDT which involved relevant specialists.

Systems for recording clinical interactions with patients were not always effective and records were not always available to all staff. There was a risk that prescribers did not have access to all relevant information to ensure safe prescribing. This included relevant outcomes of MDT discussions, and 6 week follow ups with patients by other health care professionals. Leaders acknowledged gaps in record keeping and stated that improvements were being implemented.