Harpal Clinic St. Paul's

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

The service was in breach of legal regulation because:

We found gaps in mandatory training in safeguarding adults and children and infection prevention and control.

Recruitment checks were inconsistently recorded. For example, the provider had not followed their recruitment policy which required two references per staff member.

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.

The service had established daily stand-up meetings, as well as regular clinical, new business, and staff meetings to facilitate the sharing of service related information. Staff reported feeling supported and able to raise concerns and described a workplace culture characterised by compassion and understanding. Managers actively encouraged openness and transparency, particularly when things went wrong.Processes were in place for reporting incidents, near misses, and safety events. There was also a system for recording and investigating complaints. When errors occurred, staff offered apologies and provided appropriate support to those affected.

There were policies and processes in place to support workflow and pathways for appointments, correspondence, and patient sample management. This included a buddy system to ensure pathology results and other tasks were managed in a timely manner where staff had taken planned or unplanned leave.

The service had safeguarding policies in place, and staff were aware of them. However, the policies did not include contact details for the local safeguarding team, which would be necessary should a staff member need to make a referral. We reviewed four staff training files and found that none included certificates for safeguarding children training, and two staff members had not completed safeguarding adults training. Although the provider stated that individuals under 18 are not treated by the service, they acknowledged that children may occasionally attend with an adult. Not all staff we spoke with were able to demonstrate a clear understanding of safeguarding procedures.

Following the assessment, the provider forwarded safeguarding certificates for two members of staff. They informed us that a standard process had been introduced to ensure training is consistently logged in individual staff files, and oversight measures were put in place to maintain complete training records. The provider also updated their safeguarding policies to include contact details for both the local adult and children’s safeguarding teams, ensuring staff had immediate access to referral information when needed. All staff were required to complete safeguarding adults and children training. As part of ongoing assurance, refresher sessions were delivered to reinforce safeguarding responsibilities.

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

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

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

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

Staff were appropriately qualified. The relevant professional was registered with the General Medical Council and was up to date with revalidation.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

There were a range of clinical and non-clinical roles within the service. Staff were working within their agreed areas of competence.

Disclosure and Barring Service (DBS) checks, which help identify whether a person has a criminal record or is barred from working with vulnerable groups, were not consistently documented. One file lacked a DBS check entirely, while another included only a French equivalent from 2022. There were no up-to-date risk assessments in place for staff without a DBS check.

Our review of four staff files revealed gaps in mandatory training. Not all staff had completed essential courses, such as basic life support, fire safety, infection prevention and control and information governance.

Following the assessment, the provider submitted most of the previously missing recruitment and training documentation. They told us that all staff now have valid DBS certificates on file, and outlined several measures taken to strengthen compliance. For example, they introduced a process to routinely monitor DBS expiry dates and proactively request renewals before certificates lapse. Practitioners have been encouraged to register with the DBS update service to ensure continuous validity and prevent any gaps in coverage. An additional layer of HR oversight has been implemented to verify that DBS evidence is properly documented and readily accessible for inspection. Recruitment documentation has been standardised to ensure that two references are obtained and recorded for all staff in line with policy, and any exceptions, such as referrals via known clinicians, will be fully risk-assessed and documented.

Recruitment procedures included checks on identity, previous conduct (via references), and, for clinical staff, verification of qualifications and registration with the appropriate professional body. However, the service’s recruitment policy required two references per staff member, and only one of the four files reviewed met this standard. One file contained a single reference, and the remaining two had no references documented. The provider explained that one of these staff members had been verbally referred by a doctor known to the service.

The service had systems in place to assess and manage the risk of infection. A designated lead was responsible for infection prevention and control (IPC), and the provider reported that all staff had received relevant in-house IPC training. However, when we reviewed three staff records, we found no documented evidence of IPC training in any of them. Cleaning schedules were in place and adhered to, and the service completed risk assessments and audits, taking appropriate actions to mitigate identified risks. Following the assessment, the provider informed us that staff IPC training had been documented retrospectively, a standard process was introduced to ensure future training is consistently logged in individual files, and oversight measures were put in place to maintain complete training records.

As part of our assessment, a CQC national clinical advisor conducted searches of patient records on the service’s clinical system. Overall, the searches indicated that medicines were effectively managed. Clinical staff maintained comprehensive records of consultations and treatments and followed evidence-based guidance.

However, we identified some areas for improvement. One patient who had been prescribed a medication for weight loss did not have their weight documented in the clinical record. Additionally, there was no documented discussion regarding the off-licence prescribing of melatonin. The provider informed us that the patient had signed a consent form for off-label prescribing; however, these are distinct medical concepts. Following the assessment, the provider updated the consent form to reflect the correct terminology, implemented system reminders to ensure weight is recorded when prescribing weight-loss medication, and delivered refresher training to staff on documentation standards and safe prescribing practices.

In another case, a patient had not received the recommended number of scans for their condition, and their treatment-specific consent form did not indicate the need for regular scans. For a patient with a diagnosis of bladder cancer, we found no evidence that the service had liaised with the patient’s NHS urologist following the diagnosis to inform them of the treatment being provided, raising concerns about coordination and continuity of care. Following the assessment, the provider informed us that a protocol had been introduced to ensure documented liaison with NHS specialists for patients with significant diagnoses.