Archived: Schoen Clinic Chelsea

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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

The service provided safe care and had enough staff to deliver care for patients. The environment was clean, well-maintained and fit for purpose.

Staff assessed and managed risks to patients and themselves well at the beginning of each session. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, medicines. The service managed patient safety incidents well.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There had been no serious incidents in the previous 12 months.

The provider had a clear process for managing and reviewing incidents. All staff knew what incidents to report and how to report them using the electronic incident reporting system. Staff told us that they would report any incident of harm, potential harm and/or risks to safety in line with clinic policy. The service followed the Patient Safety Incident Response Framework (PSIRF) for reviewing serious incidents. Learning was shared through newly introduced lessons-learned meetings, where incident reports were reviewed, themes identified, and actions for improvement documented.

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, for example the service had apologised to a patient where there had been a data breach with their records.

There was evidence that changes had been made as a result of feedback.

Staff received feedback from investigation of incidents, both internal and external to the service at the morning meeting, reflective practice, multidisciplinary team meetings, individual supervision and clinical governance meetings. This was to ensure that any actions were taken to manage or remove risks.

We scored the service as 3. The evidence showed a good standard. The service worked with people and their partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. Staff ensured continuity of care, including when people move between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Patients referred themselves to the service. Most people booked online, but they could also call, walk-in, used the clinic website or send an email.

Following initial triage by the administration team all referrals were screened weekly by the multi-disciplinary team (MDT) to ensure that the needs of the patient could be safely met. The service had a risk exclusion criterion to ensure that patients’ needs could be safely met. Patients told us that they were provided with information about the service and how clinicians were matched to clinical need.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Staff worked collaboratively with GPs, inpatient and community services to ensure continuity of care through shared care agreements.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. At the time of the inspection, 100% of staff were up to date with their level 2 safeguarding adults and children training. All staff said they had training appropriate for their role on how to recognise and report abuse, and they knew how to apply it. Staff felt confident that if they did raise concerns they would be listened to and action taken.

The registered manager was the safeguarding lead for the service and was trained to Level 4 in safeguarding vulnerable adults and children. As the lead they provided oversight and support for all safeguarding processes.

All interview rooms displayed a safeguarding flow chart with clear guidance and contact details for statutory organisations, including the local authority children’s safeguarding team. This ensured staff had immediate access to essential information to make safeguarding referrals or seek advice when concerns arose.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies such as the local authority safeguarding teams.

Staff were committed to taking immediate action to keep people safe from abuse and neglect, for example a consultant psychiatrist described the actions and support taken to keep a young person safe and referring on to relevant services.

The provider followed safe procedures for children using the service. Children would always be accompanied by a parent or guardian.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients told us they were involved in managing risk and contributed to their risk management plans. They told us they were provided with information through clinic letters, emails and the website on who to contact in a crisis and out-of-hours arrangements for support or if their condition worsened.

We looked at 6 risk assessments and risk management plans.

Staff developed risk assessments that were person-centred, comprehensive, regularly reviewed and up-to date. All risk assessments were developed with the patient, young person or carer. Patients’ risks were assessed at the point of referral and at each appointment. If patients presented with risks that were outside the scope of practice, the service would signpost or refer them to other appropriate services based on their individual needs. Individual patient risk was reviewed at each session. Care and treatment records detailed any risk discussions that the consultant psychiatrist had with individual patients.

Staff recognised and responded appropriately to changes to risks in patients. Where appropriate risk assessments included crisis plans and information on who to contact in an emergency out of hours. Where appropriate staff completed a safety plan with individual patients.

The number of patients on each consultant psychiatrist’s and therapist’s caseload was well managed to allow enough time to treat each patient. All consultants and therapists had access to operational and administrative support. The service had an operations manager who worked closely with the clinic director to ensure the smooth running of the service and that staff had the resources they needed to deliver safe and effective care. Any operational challenges were dealt with promptly.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Patients and carers told us the clinic environment was always clean and felt safe.

Staff did regular risk assessments of the care environment to ensure the environment was safe for patients. All interview and therapy rooms were locked when not in use and staff escorted patients from and to the reception area after each session.

Nurse call wall alarms were available in all rooms used by patients visiting the clinic. Staff were shown how to use the alarm system as part of their induction.

The service had closed circuit television (CCTV) in all communal and corridor areas. The manager used CCTV for reviewing incidents that occurred as part of their investigations.

The premises were safe, clean, well equipped, well furnished, well maintained and fit for purpose. There was an Automated External Defibrillator (AED) machine in the main reception area. This was checked regularly to ensure that it worked. There was appropriate signage, so staff knew where it was located. Staff had completed simulation-based learning which included using the defibrillator during a medical emergency.

Fire escapes were clearly signposted on each floor. Fire equipment was regularly checked to ensure it was fit for purpose. For patients with mobility difficulties fire evacuation chairs were available on the first and second floor. Staff completed a fire drill in July 2025. Actions from the fire drill included staff undertaking additional training around the evacuation process. 90% of eligible staff were up to date with their fire safety training.

We scored the service as 3. The evidence showed a good standard. 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.

Patients told us there were enough staff available.

The service had enough staff of different disciplines, who knew the patients and were appropriately trained to keep them safe from avoidable harm. The service had a range of employed and sessional clinicians and therapists.

Caseloads were managed so that individual staff could give each patient the time they needed.

There was adequate medical cover within the service. There were staff trained in first aid and basic life support who could attend to physical health emergencies.

Staff had completed and kept up to date with their mandatory training. Staff had completed and kept up to date with mandatory training, with compliance at 90%. The training was appropriate for the patient group using the service. Managers monitored mandatory training and alerted staff when they needed to update their training.

The service carried out employment checks on staff, including criminal background checks, qualifications and right to work at the time of recruitment and on an on-going basis where appropriate. The clinic director ensured that all consultant psychiatrists had all the checks and agreements in place before they were granted practicing privileges. Practicing privileges enable doctors to practice in hospitals without being employed by them. We reviewed 3 records for doctors working at the service and these contained details of all the checks that were required to be carried out.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection.

Patients and carers told us the clinic environment and therapy rooms were clean and appropriate to their needs.

80% of staff had completed infection prevention and control training.

All areas were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that all areas were cleaned regularly. The service contracted with an external cleaning company.

Staff followed infection control guidelines, including handwashing. Hand sanitising gels and wipes were available throughout the clinic. The service completed hand hygiene and infection control audits. Staff made sure equipment was well maintained, clean, tested and in working order.

All electronic equipment had an up-to-date portable appliance test carried out, and all clinical equipment had been calibrated to ensure safety and compliance.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Patients told us they were involved in discussions about their medicines and provided with information on the risks and benefits of medicines prescribed.

The service used robust systems and processes to safely prescribe medicines. No medicines were stored on site. There were two systems in place: one for controlled drugs and another for standard prescriptions. Standard prescriptions were managed electronically through the patient record system, which maintained an automatic log and allowed the medical director to review prescribing activity. Prescriptions could be printed or sent directly to partner pharmacies.

There were policies and procedures for prescribing medicines in accordance with national guidance. Prescribing practices were monitored through regular audits and peer review discussions to ensure compliance with best practice.

There were appropriate arrangements for the safe management, use and oversight of medicines and controlled drugs. Staff kept records and carried out audits of controlled drugs stationary to ensure the safe and effective management of controlled drugs.

The clinic director served as the Controlled Drugs Officer for the service and participated in meetings of the London‑wide Controlled Drugs Accountability Officers Group. They shared any learning from the group with the wider team.

Staff reviewed the effects of medicines on patients’ physical health regularly and in line with NICE guidance. For example we saw that regular blood tests were carried out for a patient prescribed Clozapine. Where patients were prescribed ADHD medicine blood tests and ECG results were reviewed before commencing treatment.

The provider produced a monthly mental health newsletter detailing all medicines and safety alerts. The service had an effective mechanism in place to disseminate and act on these alerts. Staff we spoke with confirmed that this process worked well.