The Rostra 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement.

This service scored 41 (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 did not have a proactive and positive culture of safety based on openness and honesty. Staff did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

However, staff listened and responded to patient’s concerns about safety. For example, during consultations and captured these in post-operative summary letters.

The manager told us the service had reported no safety incidents for the last 12 months. This meant we could not evidence they would take appropriate actions and follow up any areas for learning with staff.

However, the RM provided one recent learning example. This entailed a patient who informed the RM that one of their tablets elevated their deep vein thrombosis (DVT) risk. DVT is a condition which occurs when a blood clot forms in a deep vein, usually in the legs.

The RM confirmed the service’s last reported DVT was in September 2024. This was subsequently reviewed at their board meeting. They wrote to the patient’s GP as they were under haematology. The RM remarked that the patient’s haematology team gave positive feedback about their follow up actions.

However, we requested but did not receive this written report or any other learning from patient safety events or incidents. This meant we could not verify what the RM told us on-site.

We found very few examples of a learning culture on-site. Staff could not tell us of any learning from reported incidents or patient safety events, notifications, health and safety occurrences, complaints, infections, information governance breaches or security alerts. There was also no ‘you said, we did’ examples displayed, no ‘how to complain’ or other support services contacts or information.

The RM told us any clinical incidents would be discussed, reported and minuted at bi-annual formal board meetings.

However, minutes of executive board meetings we reviewed did not contain any clinical information such as performance data. This meant we could not ensure learning was shared between staff or across provider networks.

After our on-site assessment, we were sent the provider’s blank incident report form. This should be completed when a dangerous occurrence, near miss or incident occurs. On-site we found examples of dangerous hazards and near misses. This meant we could not ensure staff knew when or how to complete incident reports.

We were also sent the provider’s in-date incident reporting and investigation policy and procedure. On-site staff could give us no examples of incident investigations. This meant we could not ensure they followed the procedure to improve safety in their service.

The service did not always work well with people to establish and maintain safe systems of care. They did not always manage, monitor or document people’s safety. For example, vital information, including around local anaesthetic was missing from patient records. Staff conducted no clinical reviews or audits.

However, staff ensured their patients had continuity of care, including when people moved between different services. For example, by sending discharge letters to their GP.

The service gained no internal assurances patients were receiving safe and effective care. Staff relied on longstanding clinical and evidence-based outcomes for their procedures.

We reviewed eight patient records. We found all eight of these were lacking vital information. For example, no observations, post-operative treatment or information were included in any. Furthermore, no prescription sheet or information for local anaesthetic was included in four of the patient records. This meant we could not ensure patient records contained all key clinical and background information.

Patient’s procedures were as outpatients; they were ambulatory and not sedated. The RM allocated individual patient identifiers on their records. They routinely gave patients undergoing laser varicose vein procedures post-operative advice. Nine bullet points outlined the main pieces of advice with a helpline phone number patients could contact.

Patients told us staff checked they were fit and fully recovered post-procedure before leaving the clinic. They confirmed the RM booked in review phone calls, and scheduled bi-monthly in-person follow up appointments.

Patients were given clear steps and verbal and written guidance to follow for optimal recovery before leaving the clinic. Patients received the same post-procedure guidance as they would in the NHS.

Staff gave all patients the RM’s mobile number as a first point of contact. If patients needed an urgent follow up appointment, staff would see them the same day or the next day. Staff could usually reassure and resolve post-procedural issues such as any discomfort by phone.

After our on-site assessment we were sent the provider’s in-date records management policy. The policy stated, ‘records should be full and accurate to the extent necessary’ and ‘it is essential any important and relevant information be recorded’.

However, on-site we found staff did not fully complete records. This meant they did not comply with policy.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff did not share concerns quickly and appropriately.

We saw evidence the RM as clinical lead had completed safeguarding adults up to level 3, and safeguarding children training to level 2. The HCA told us they were also trained to adults safeguarding level 2. We requested but did not receive evidence of the HCA’s training.

Staff confirmed they had raised no safeguarding referrals in the 12 months before our assessment.

On-site staff could give us no examples of safeguarding concerns they had raised to keep people safe.

The clinic displayed no safeguarding information anywhere on the premises. There were no local authority or other support services contacts or information for patients to use. This meant we could not ensure the service effectively or consistently safeguarded people from abuse and improper treatment.

After our on-site assessment we were sent the provider’s in-date safeguarding vulnerable adults’ policy. The policy stated the staff should be able to access a local trust or named professional safeguarding lead. It also reminded staff members of their professional duty to report concerns of abuse.

However, the service had no designated safeguarding lead. This meant we could not ensure staff followed this policy.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service still had no formal means of recognising or responding to patients at risk of deterioration.

Staff still did not record any observations in patient records. At the previous inspection we found staff did not review or update their assessments of risk to service users. We found staff were monitoring, but still not recording patient’s blood pressures or any other observations before or during laser procedures. There were no blood pressure readings in any of the eight sets of patient notes we reviewed. Staff told us they would recognise other vital signs of deterioration. This meant we could not ensure staff knew or were able to respond promptly to patients who were deteriorating.

Furthermore, the RM explained blood pressure monitoring contradicted clinical best practice guidelines and did not help them keep patients safe. They added none of their consultant ex-colleagues monitored patient’s vital signs during their procedures or understood the benefit of doing so. We were not sent the clinical guidelines staff referenced onsite.

We saw no risks were documented to patients in their post-consultation emails. This meant we could not ensure staff identified or discussed all relevant risks with patients’ pre-procedure.

The service had no resuscitation trolley on-site. The HCA explained in the event of a patient suffering a cardiac arrest they would use the automated external defibrillator (AED) outside their high street chemist. They had completed life support training. However, they were unsure which level of training they had completed. We could not locate the certificate to evidence this in their staff file. There was also no proof of life support training in the RM’s file. This meant in the event of a medical emergency, we could not ensure staff could respond safely, effectively or promptly.

After our assessment, the RM sent proof of the HCA’s basic life support training. However, it was not dated.

We requested but did not receive the service’s urgent transfer policy. The service did not provide any completed risk assessments relating to the lack of life support equipment. In the event of an emergency, staff told us they would call 999. Staff told us they had never had an urgent or unplanned patient transfer to a local hospital.

After our on-site assessment we received the service’s in-date deteriorating patients and resuscitation policy version 4. The policy stated, ‘all nursing staff will be trained to perform basic life support (BLS) and shall update and practice the techniques on a training mannikin periodically in accordance with the organisation’s policies.’ However, we were unsure how frequently staff could practice as no automated external defibrillator (AED), mannikin or other lifesaving equipment was available on-site. It also stated, ‘evidence of team’s member’s resuscitation training will be recorded in their personal CPD record.’ However, during our on-site assessment we found no life support training record in either staff file. The policy stated, ‘the process and outcome of all resuscitation attempts will be the subject of audit.’ However, the service undertook no audits or clinical audit points (CAP) as part of a CAP programme. This meant the service was not adhering to policy.

We requested but did not receive the service’s comprehensive pre-treatment screening criteria by the given deadline. This meant we could not ensure staff protected people from risk of harm, including to themselves.

After our on-site assessment we were sent the NICE guideline NG51 on suspected sepsis. Rather than a standalone sepsis policy, staff’s management of sepsis fell under the service’s broader Infection Prevention and Control (IPC) policies. However, there was no guidance or information the service staff could follow. We were unsure how staff would identify patients with suspected sepsis or adhere to the guideline as they did no screening.

The service did not always detect and control potential risks in the care environment. Staff did not ensure equipment, facilities and technology supported the delivery of safe care.

The maintenance and use of facilities, premises and equipment did not keep people safe, secure or free from hazards.

The registered location premises was not secure. The building had a rear door staff could use in case of emergency or fire. During our assessment, this rear door remained unlocked. The stock room door key was left in the lock. This meant people could potentially enter and help themselves to stock and medicines.

We found issues around safe and secure storage of stock and medicines. Several of the stock items had expired. We found a biohazard body fluid clean up kit which expired in May 2023. We also found expired syringe needles and sterile gloves. The latter were laid out to be used for regulated activity with patients on the day of our assessment. The RM had purchased them in June 2025 from an online retailer through a medical supplier they trusted. The RM confirmed they did not internally check expiry dates or stock quality upon receiving the items.

Other stock was stored on the kitchen floor, piled high in boxes which could potentially present a safety risk. Clinical and general waste bins did not have lids. Tubs and fluids in dirty containers were stored on top of patient notes.

Staff stocked no O2 cylinders if a patient needed emergency transfer to hospital.

We asked staff why so much stock had expired. The HCA said much of it applied to other services or were out of scope. The RM said they had discontinued using a stock checklist after losing an NHS contract. They ordered stock and medications from the local pharmacist ad-hoc. This meant we could not be assured staff internally completed any itinerary or stock checks. There was a risk that expired, and improperly stored consumables could be defective and non-compliant.

After our on-site assessment, we were sent the service’s stock audit. This detailed all their stock, suppliers, expiry dates and levels required. However, staff had not yet reviewed or audited any stock. This meant we were unclear how often or effective this audit would be.

The service had no designated health and safety lead or fire officer to keep statutory requirements up to date. The RM could not locate their fire policy on site. The service had no agreed fire evacuation procedure process or meeting point. The premises had no plan or signage indicating where staff should exit the premises and assemble. Staff did not practice any drills or scenarios. This meant in the event of a fire or serious incident staff would be unprepared and unable to exit the premises safely. This potentially put their lives at risk.

After our on-site assessment, we were sent the providers recently verified general health and safety policy statement. The statement read; ‘risk assessments, audits and general inspections will be undertaken at regular intervals by those trained to do so. This will enable management to identify significant hazards and plan for their elimination, reduction and control.’ However, on-site despite us finding significant hazards, we found staff had completed no health and safety risk assessments, audits or inspections. This meant staff were not following this policy.

We saw two new powder fire extinguishers had been externally serviced by the contractor in the last year. Extinguishers were suitable for use on classes A to D as well as electrical fires. We also saw a fire alarm with a button to break on the upper floor landing, and smoke alarms on both floors.

However, staff had never tested alarms and did not know if or how they sounded.

Their upstairs office door was fireproof, but this had no signage indicating as such. Staff told us their local fire station was just up the road. This meant staff downplayed and did not sufficiently mitigate the risks associated with a fire outbreak.

After our assessment the RM sent a completed fire risk assessment checklist dated 6 September 2025. This included completed action on 7 September to obtain and display general fire notices and evacuation signage detailing the action to take in the event of a fire.

However, not all questions were compliant. For example, the RM answered ‘No’ to there being a suitable electrical fire alarm system. He had not included a corresponding action in the action plan.

We saw evidence of the service’s in-date fire procedure policy after leaving site. The policy’s second point in case of fire is for staff to make certain they are familiar with the means of escape. When we asked staff on-site, they had no agreed evacuation route. The policy states in bold type staff should sound the alarm if they discover a fire. However, on-site staff were unsure how alarms sounded or if they worked. This meant staff did not adhere to their policy.

The RM still did not ensure the local rules for the safe use of the diode laser were updated. However, the RM reviewed their laser’s local rules yearly. They told us no updates were needed as they used the same laser, wavelength, protection personal equipment (PPE) and guidance as before. As a result, there would be no benefit, other than acknowledging no changes.

The service’s laser console was on permanent loan from a private company. The machine notified the user when it needed servicing using self-determining software. The RM would approach the company to service if two years had elapsed. The laser and all electrical equipment was safety tested every three years. We also saw evidence the RM was trained to use the diode laser.

We saw specialist equipment such as the ultrasound probe had passed the latest test.

After our on-site assessment, we were sent the laser’s annual service and test report form from July 2025. This showed the laser had passed all inspection and electrical safety tests. However, the form was unsigned by the engineer or customer. This meant we could not be assured staff had reviewed or signed off the test results.

We also reviewed the provider’s in-date facility and equipment policy. This helped the manager ‘ensure the safety of all employees maintaining the machinery and facilities’.

Staff reported no accidents or injuries at work. The RM told us the service had not used their accident book for 15 years. Staff had never reported injuries, diseases or dangerous occurrences regulations (RIDDORs) at work to the HSE. The RM said they could probably figure out how but had no reporting process or procedure in place. This meant in the event of an incident or accident occurring at work, we could not ensure the RM as ‘responsible person’ would be compliant with health and safety laws or know what constituted a reportable incident. Internally staff reported no clinical or environmental incidents to prevent future occurrences or keep themselves and others safe.

However, after our assessment we saw evidence, the HCA was the service’s first aider. They had completed emergency first aid at work training.

After our on-site assessment, we were sent the provider’s in-date RIDDOR policy. However, on-site we found staff had not undertaken any reporting or record keeping of RIDDORs as outlined. This meant we could not evidence they complied with policy.

Managers did not ensure staff were qualified, skilled and experienced. They also did not record how staff received effective support, supervision and development.

However, the service had enough staff. They worked well together to provide safe care that met people’s individual needs.

The service only employed two clinical staff members; the RM as lead consultant nurse and a healthcare assistant who was present for all procedures.

No evidence of training completion was within both the staff files we checked on-site. We requested but did not receive the service’s latest mandatory training compliance and modules. This meant at the time of our assessment we could not ensure staff were compliant or up to date with training.

Staff had no training in statutory learning disabilities (LD) or autism. This is a legal requirement for all health and social care staff under the Oliver MacGowan code of practice since 6 September 2025. The service had no trained staff leads in IPC, safeguarding, mental health, and autism. Managers did not encourage, invest or help staff access training and development, and continuous personal development (CPD).

After our assessment we were sent the provider’s knowledge, practice, insight (KPI) training and development programme. However, on-site we had found no record of staff’s progress through the programme. This meant we were unsure of their relevant business knowledge or development.

After our assessment the provider also sent their in-date learning and professional development policy. The mandatory training section stated ‘the CQC will need to see…records kept in personnel files of all training attended. This includes statutory training in fire procedures and health and safety’. However, onsite we did not see records of training in personnel files and staff were unsure of fire procedures such as evacuation. This meant staff were non-compliant with policy.

We reviewed the service’s recruitment and selection policy. It mentioned an operations director 17 times, despite staff not mentioning them once on-site. It also outlined the need for all recruited staff to provide references. We discussed this with the RM who told us they did not see the point of running background checks on themselves as they had worked in the service as company directors for many years. We saw no references in both staff personnel files. This meant we could not ensure staff followed this policy as part of a set, clear recruitment process.

Nursing staff undertook revalidation with the nursing and midwifery council (NMC). The RM’s revalidation was due in November 2025. They used a qualified nurse at a London healthcare provider to complete their revalidation, and vice versa. At the time of our assessment, the RM were mentoring a matron ex-patient so considered asking them for revalidation. Their clinical competencies documentation was signed off by the provider medical director (MD).

After our on-site assessment we were sent evidence of the nurse competencies for procedural ultrasound. This had been signed by the MD assessor in March 2010. We could see no evidence the competencies had been reviewed or revised since.

We found no systems in place for the proper and safe recruitment of staff. We reviewed both staff personnel files including the registered manager. Both were missing important documentation. For example, the RM and HCA files both had no proof of identity, references, health clearance, driving licence checks or training records.

All documents contained in files were out of date, incomplete or both. For example, the RM’s latest enhanced disclosure and barring service (DBS) checks were from June 2013, and the HCAs from 2006. The RM explained they did not need to renew enhanced DBS, and healthcare professional registrations had been sent electronically for several years.

After our on-site assessment, we were sent staff’s latest enhanced DBS checks from September 2025.

There was no staff induction process in place, as the service did not recruit or need any extra roles and had no vacancies. Instead, the HCA had completed a competency assessment. This ensured they had knowledge, skills, abilities, and behaviours to perform the role successfully.

Appraisal professional development plans (PDP) from 10 January 2025 were blank other than the front sheet’s tick boxes. Staff files contained no 1-2-1 records as they discussed emerging issues on an ad-hoc basis. This meant we could not ensure staff were suitably trained or maintained competency for their roles.

Staff files also contained irrelevant or discontinued documentation for their role. This meant we could not ensure staff were experienced, qualified or had the right skills and knowledge to meet patient’s needs.

After our on-site assessment we were sent performance evaluation forms for both staff members dated 10 September 2025; the week after our visit. Both scored five out of five in all areas with no issues or areas for improvement.

After our on-site assessment we were sent the provider’s in-date performance review and development policy. This applied to all clinical staff which consisted of the RM/consultant nurse. However, the policy states ‘our performance review process focuses on agreeing clear objectives’. We found no objectives or review notes in both PDPs we reviewed. This meant staff were not adhering to this policy.

The service did not assess or manage the risk of infection. Staff did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Clinic areas were not clean, tidy or clutter-free.

We found mould and leaky plaster on clinic room walls. This meant the main clinical environment was not maintained and potentially unsuitable.

Products in the stock room were not stored securely or separately to comply with the Health and Safety Executive’s (HSE) control of substances hazardous to health (COSHH) regulations. There were no warning signs making people aware of these risks. This meant staff, patients and others could potentially access substances harmful to their health.

However, furniture was wipe-clean, and we saw equipment was in a good condition.

After our on-site assessment, we were sent the provider’s in-date COSHH policy. However, on-site we found no risk assessments or controls outlined in the policy were in place. This meant staff did not comply with policy.

Staff did not maintain any cleaning records. Staff told us the clinic room was cleaned at the end of each day. However, we saw no ‘I am clean’ or equivalent stickers in use. We requested but did not receive any cleaning checklists or audits. This meant we could not ensure staff sufficiently or regularly cleaned all areas to prevent patients from cross-contamination.

We reviewed the provider’s in-date clinical area cleaning policy sent after our on-site assessment. The policy referred to domestic staff, of which the service had none. It also stated monitoring and auditing of cleanliness standards was undertaken by all staff and recorded daily. However, on-site we found staff maintained no cleaning records. This meant they did not comply with this policy.

We observed two non-invasive varicose vein procedures on the day of our assessment. Clinical staff did not comply with correct use of Personal Protective Equipment (PPE). We observed staff did not wear sterile gowns or aprons during invasive procedures, just the same uniform for all patients seen and treated. We found sterile stock such as gloves had expired. All sterile equipment was put on the same tray during procedures. This meant a sterile environment was not maintained in treatment rooms, leaving patients and staff potentially susceptible to risk of infection.

The RM confirmed the service had no clinic-acquired infection cases to report since registration. We reviewed the service’s in-date infection prevention policy. Staff did not adhere to the protective clothing section relating to plastic aprons. On-site we saw staff not wearing disposable or fluid repellent gowns as advised. This meant they did not comply with policy.

The service did not ensure systems were in place to monitor infection prevention control (IPC). This meant staff could not robustly assess any IPC related risks. For example, they had no designated IPC lead and staff undertook no IPC checklists, reviews or audits. The clinic entrance displayed outdated Coronavirus compliance and COVID-19 secure information from 2020.

We were sent the provider’s IPC monthly review checklist post assessment. This covered nine different standards to ensure staff cleaned all areas. However, the checklist was blank, unsigned and not dated. This meant we could not ensure staff had undertaken any IPC checks or reviews.

We were also sent the provider’s aseptic technique policy. This outlined the general recommendations of asepsis which included using sterile PPE, fluids and packs. However, on-site we found staff stocked expired sterile equipment, and did not wear sterile gowns or aprons to maintain a sterile field during procedures. This meant they did not comply with policy.

We were also sent the provider’s in-date risk assessment for healthcare associated infections (HCAI) policy. The policy mentioned an infection control rolling programme of audits. However, on-site we found no risk assessments in patient records or anywhere else. This meant we could not ensure staff mitigated all infection-related risks. Staff still undertook no audits, which meant we could not ensure they complied with policy.

We saw staff comprehensively hand washing pre and post procedure. Handwash basins were present in clinic along with alcohol sanitiser.

We reviewed the provider’s in-date hand hygiene policy and guidance on how to decontaminate hands sent after our on-site assessment. This outlined why and when hands needed decontaminating, along with commonly missed areas during handwashing. However, the service had completed no hand hygiene checklists or audits since February 2023. Copies of staff’s individual hand hygiene checks were in their files. This meant we could not ensure they always complied with policy or guidance and stayed aseptic.

We saw clinical waste was stored, segregated (into clinical and non-clinical) and disposed of correctly. The service used a private clinical waste contractor. The contractor collected waste ad-hoc according to need. The RM told us there were never collection delays or a lack of storage. After our on-site assessment we reviewed the service’s in-date contractual agreement for controlled waste.

The provider had an in-date safe disposal of clinical and domestic waste policy. However, the policy mentioned a contract with the trust, which the service no longer had. On-site we found expired stock items were not returned to the pharmacy, and staff did not abide by the COSHH regulations as the policy stated. This meant they did not comply with policy.

The service did not ensure medicines and treatments were safe and met people’s needs, capacities and preferences.

However, people were involved in planning their medicines.

The service did not safely manage, store or administer medicines. Staff did not check medications to ensure they were safely, securely or appropriately stored. We observed staff not checking the expiry dates of medication and related equipment (local anaesthetic and ampule) during procedures.

The service had no medicines lead or pharmacist visits to complete medicine audits or assurance checks. Although medicines were in a designated cupboard, the stock room door was left unlocked when no surgical procedures or regulated activity was being undertaken. This meant medicines were potentially accessible to anyone.

During our assessment, the back door to the premises remained unlocked. The stock room door key was left in the lock. This meant people could potentially enter and help themselves to local anaesthetic.

At the last inspection the service did not complete medicine audits. At this assessment the service still did not complete medicines checks or audits. The service had no medication governance processes or systems in place to report any errors, related incidents or issues.

We reviewed the provider’s in-date management of medicines policy sent after our on-site assessment. This policy stated, ‘the clinical lead should ensure all medications are kept in a safe and secure manner at all times and that access is controlled’.

However, on-site we found staff did not ensure medicines were stored safely or securely. This meant they did not comply with policy.

The RM and a local pharmacist prescribed medicines. The service only used and stored one medication on-site in the storeroom. This was the local anaesthetic lidocaine.

The RM as clinical lead prepared the local anaesthetic in advance. They drew up the drugs in the anaesthetic room pre-procedure. The RM recorded prescriptions in the patient’s written records. Patients pre-obtained any prescription medication from a local pharmacy, or the RM gave the patient a prescription to collect themselves. For example, a patient told us staff prescribed them blood thinners post-procedure.

The provider’s managing director was registered on the central alerting system (CAS) with the medicines and healthcare products regulatory agency (MHRA).