The Sloane Court 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 where a rating has been applied. This key question has been rated as requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 18, Regulation 15, and Regulation 12. Staff did not receive regular updates for their mandatory training. There were no processes in place to ensure associate clinicians had up to date training and documentation. The service did not carry out fire safety drills in line with statutory requirements. Risk assessments were not completed for all patients.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incidents to report and how to report them. Staff reported incidents to the general manager and registered manager. These would then be logged onto an incident log, depending on the type of incident. For example, health and safety incidents or serious incidents.

Managers reviewed all reported incidents. Incidents were discussed in monthly governance meetings, weekly operations team meetings and keep in touch meetings with clinical staff.

In the last 12 months there had been 4 serious incidents. Three of these serious incidents were patient suicides and 1 incident was ruled an accidental death. Managers investigated the circumstances around these deaths, and they did not identify any provider failings. When a death occurred, staff were required to complete a detailed coroner’s report to support the investigation, even if one had not been formally requested.

Learning had been identified following serious incidents, for example, ensuring all patients were aware of the potential cost of a course of treatment prior to a patient beginning their treatment with the service. The service had also offered supportive sessions with the relatives of those who had died.

We saw evidence of discussions following recent incidents in the governance meetings. However, staff were not always able to identify learning that came from investigations of serious incidents.

Staff were debriefed and received support after serious incidents. We saw documented discussions where support was offered to staff following patient deaths and a recent staff harassment incident.

Duty of candour is a legal requirement, which means providers must be open and transparent with patients about their care and treatment. This includes a duty to be honest with patients if something goes wrong. Staff were aware of the need to be open and transparent, including after an incident.

There were systems in place for processing information relating to new patients. Patients were able to be referred through a professional, such as a GP, or a self-referral. Both referral routes required a referral form, containing information such as past and current treatments.

The referral process ensured that enough information was received to determine if the patient’s needs could safely be met by the service. The registered manager reviewed all new referrals. More information was requested from the patient or referrer at this stage if needed. If initially deemed appropriate for the service, the referral would then be sent to the most suitable clinician, for their review.

The service worked with other providers to deliver shared care. For example, the service often worked with GP surgeries to prescribe medicines.

Staff had an understanding of identifying and managing safeguarding concerns, but we found some areas that needed improving around training compliance and notifying CQC of safeguarding concerns raised to the local authority.

Staff had an understanding of identifying and managing safeguarding concerns, but we found some areas that needed improving. Not all staff had received the appropriate level of training as outlined in the service policy. The service had not notified CQC of a safeguarding referral made to the local authority, which is a statutory duty.

The operations staff had received level 1 safeguarding adults training. The safeguarding policy stated all staff should have safeguarding children’s training; however, the operations staff had not received this training. The service did not monitor the training status of their associate clinical staff members.

However, the staff we spoke with understood the procedures they would follow to raise a safeguarding concern. All safeguarding concerns went through the registered manager and general manager.

The service had links with external safeguarding professionals. Staff told us they frequently discussed safeguarding concerns with the external professionals for advice.

The registered manager was the safeguarding lead for the service. The staff we spoke with were aware of this, and would raise concerns with them as needed.

The service did not have clear and consistent processes for recording when risk had been assessed.

We reviewed the care and treatment records of 6 patients. Assessed risks were not always recorded clearly in patient notes. Managers told us staff should carry out risk assessments for each patient when they were new to the service and report any risks within the assessment letters. In 2 of the 6 records we looked at, the assessment letters did not include information about assessed risk, including whether they had assessed that there were no risks. The service recognised that documentation needed to be improved, and all letters must outline if risk had been assessed and what risks were, including if there were none.

Patients told us they felt involved in their care and treatment plans. Patients were aware of how to get additional support should their condition worsen. Two records documented how their patient could get support out of hours or in a crisis.

There were appropriate indemnity arrangements in place to cover potential liabilities.

The service ensured their clinic was clean and well maintained. The clinic had 3 meeting rooms, a waiting area and a patient toilet.

The clinic was on the lower ground floor. There was a room available in another nearby building to meet with patients if there were any concerns with using the staircase. Some staff told us it would be useful to have a bigger clinic, with more meeting rooms available.

A patient told us there was sometimes some confusion if their appointment was in person or online, as they have attended both types of sessions. They also told us the doorbell for the separate ground floor meeting room was not labelled correctly, which led to confusion.

There was a health and safety risk register in place, which included potential incidents such as trips, slips and burns.

There was a business continuity plan in place which was monitored and reviewed. This included incidents such as power failures, cyber attacks and severe weather.

The service had a fire safety policy, detailing the evacuation procedure. There were fire extinguishers in place, which were audited by an external company. The service had not been completing fire evacuation drills, which they should have done in line with fire safety requirements. The service made a plan following the inspection to implement and document these drills.

For online appointments, staff verified patients’ identity by asking questions related to their care and treatment. They did not request or check photo identity documents before consultations, in line with NHS digital guidance for all online health services.

The service employed operation staff in roles such as the general manager, patient services coordinators and medical secretaries. Clinical staff were associate team members and not directly employed by the service.

The clinicians specialised in different areas, allowing the service to offer treatment to a range of patients. For example, general psychiatry, older adult care and Attention Deficit Hyperactivity Disorder (ADHD) assessments and treatment.

The service had onboarded a consultant pharmacist who worked alongside other clinicians offering specific sessions with their patients to discuss medicines in more detail.

The service also had associate consultants in a range of operational areas, such as human resources, information governance and finance.

All staff completed an induction when they began working for this service. Operations staff had a 4 week induction which involved training and shadowing activities. Clinical staff received information when they were appointed, and met regularly with managers while settling in. These meetings were not documented to show what support was offered to newer members of staff.

Operations staff received check in meetings every 6 weeks with the general manager, although there was no standard template used, and these meetings were not documented. These meetings were for staff to discuss any personal or work related issues with their line manager. Staff also had 2 weekly team meetings with their manager and co-workers. These meetings focused on work related concerns and updates. Appraisals were held yearly for operations staff.

Clinical staff received supervision, appraisals and revalidation external to the service. The service did not have a policy on how they would receive or record assurance of these taking place and did not hold information about this for their clinicians, at the time of inspection. The service did not carry out competency assessments.

Staff did not have regular updates to their mandatory training, in line with service policy. Training was provided on induction, however there was no programme for regular scheduled mandatory training. For example, some staff had last completed fire safety training and information governance training in 2020. Some staff had last completed basic life support training in 2023. Only 3 staff had completed infection prevention and control training. Staff had not completed neurodiversity awareness training. Managers were now aware of this and were looking into options for regular updates to training.

Safe recruitment practices were followed. When associate clinicians were onboarded they uploaded information, such as, professional certificates, DBS, and professional registrations. However, there was no system in place to notify managers when documents or training courses expired. A manager told us they reviewed this information manually each year, and requested documents from clinicians if needed, which was time consuming. These yearly reviews were not a documented audit.

Staff told us they had good working relationships with colleagues. Most clinical staff were referred to the service by other clinicians or word of mouth. Some clinicians had applied to work at the service through the service’s website.

The service had an infection control policy. The meeting rooms had yellow boxes to safely dispose of any sharp objects brought to the service by patients.

There were cleaning schedules and cleaning logs in place.

However, operations staff were not up to date with their infection prevention and control training. The service did not keep records of clinical staff’s training.

The service made sure that medicines and treatments were safe and met patient’s needs and preferences. Patients told us staff took their views into consideration when recommending treatment plans.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. Patients told us their doctors explained their medicines to them before treatment started, including any side effects. We saw examples of this in patient’s records.

The service had policies related to medicines in place. For example, controlled drugs policy, repeat prescribing policy and a policy to monitor the use of the medicine Valproate.

Staff managed prescription stationery appropriately and securely. Controlled drugs prescription pads were kept in a locked cupboard, in individual staff wallets. The key to the cupboard was held in a safe. However, the safe combination code had not been changed for many years, which did not uphold best practice around access to controlled items. Following the inspection, this combination code was changed.

When medicines were prescribed, staff ensured a copy of the prescription was saved onto the patient’s records. Medicines were either picked up by patient at the service, sent to a local pharmacy, or processed by an external pharmacy company. When controlled drugs were prescribed the external pharmacy company would collect the prescription from the service or the clinician’s home.

The doctors within the service received safety alerts related to medicines. If an alert related to the medicines prescribed by the service, the registered manager would re-circulate the email to the team.

Staff followed processes to ensure people prescribed medicines with specific risks received the recommended monitoring. For example, the service kept a record of the patients taking Valproate, to ensure that their physical health reviews occurred as needed.

The service carried out audits related to medicines. For example, Valproate audit and a repeat medicines audit. The consultant pharmacist carried out an audit on all prescribed medicines between 2022 and 2024 to review if prescribing was in line with national guidance. This audit found antidepressant and stimulant prescribing was in line with UK prescribing guidance. The pharmacist suggested the service reviews it's use of propranolol, which can be toxic in cases of overdose.

The service did not keep records of medicines optimisation competency assessments for their associate doctors. Service policy stated operations staff should receive training on how to manage and record prescriptions correctly, however there were no records that this had been completed.