The Mole 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 since its registration with CQC. This key question has been rated as Good.

This service scored 72 (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 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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding.

The service encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The service provided treatments to adults only. Patients’ identities were verified verbally, and photo identification was requested to confirm age where there was any doubt.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. The practice was equipped to respond to medical emergencies and staff were suitably trained in emergency procedures. There was an Automated External Defibrillator (AED) available, which was checked regularly.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The provider gave patients after-care information once treatment had been given and ensured the patient knew who to contact if there were any concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There were contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

The last fire risk assessment was carried out on 2 May 2025. The fire system was inspected regularly; the fire extinguishers were checked and there was a record of fire alarm checks. The service carried out regular fire drills.

Portable appliance testing was carried out on 23 January 2025.

Calibration of medical equipment was not carried out, because the service replaced the equipment annually, which was more cost-effective.

Legionella risk assessment was completed on 30 April 2025. In April 2025, Legionella bacteria were identified within the water system at the premises. The provider implemented a range of remedial actions, including chemical disinfection and the installation of a new boiler. Despite these measures, water sample results from October 2025 continued to indicate the presence of Legionella.

The provider informed us that a further water sample taken on 3 November 2025 did not detect Legionella bacteria. However, on 19 December 2025, the provider notified us that Legionella had been identified again in the kitchen water supply, an area not accessible to patients.

The provider had implemented interim control measures to manage the risk, including daily monitoring of water temperatures, routine flushing of outlets, and the provision of bottled water for use across the premises. The provider was working in partnership with the landlord and external contractors to address the ongoing issue and to ensure appropriate measures were in place to protect the health and safety of staff and patients.

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

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.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. However, we identified that handwashing facilities were not available in three screening rooms. Staff had access to handwashing facilities in the treatment room and kitchen area, and alcohol hand sanitiser and gloves were available in all rooms. The service had completed a risk assessment to mitigate this risk in line with national guidance.

The practice had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The environment was noted to be clean and tidy during our onsite visit, and all appropriate personal protective equipment was available for staff to use.

Feedback from people who use the service, was positive in relation the cleanliness of the environment.

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.

We reviewed 10 clinical records stored electronically on a secure system. Records were complete, accurate and up to date. Consultation notes demonstrated appropriate clinical decision-making. Staff followed established prescribing protocols and ensured medicines were prescribed safely. People knew what to do and who to contact if they experienced any unexpected symptoms.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Medicines were stored appropriately in a locked medicines fridge. Temperature recordings were taken in line with the provider’s cold chain protocol, and no concerns had been identified.

Staff regularly checked the stock levels and expiry dates for all medicines including emergency medicines.

The service stored medical gases, such as oxygen, safely and completed the required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls.