Archived: Queens 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 found that the service was not providing safe care because: Clinical records did not meet professional standards and the electronic record keeping system did not provide sufficient oversight of patient risk. The provider did not keep up to date with best-practice guidelines, updates, or safety alerts. There were no systems and processes in place to support safe information sharing or staffing, and the provider did not articulate an understanding of the importance of this. Safeguarding policies were not sufficiently clear, and the provider did not follow the policy in place.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider said they always kept up to date with literature, attended lectures, and reviewed contact from the Royal College of Obstetricians and Gynaecologists (RCOG) however, there was no evidence of this and the provider could not give any recent examples of learning or updates completed. There was no evidence of feedback collected from staff or leaders in order to support a learning culture.

There were no processes or systems in place to ensure national safety alerts were monitored or acted upon. The provider could not evidence they kept up-to-date with national safety alerts, including a recent change to contraceptives commonly used in the clinic. There was no system to identify and recall patients who were treated with medicine which may later be subject to a safety alert. Since the last inspection, there had been minor updates on the provider’s electronic database. The provider was currently undertaking training on their database and had introduced a simplistic labelling system to try and identify patients by condition. However, this labelling system was not specific enough to support effective monitoring and oversight of patient risk. There were no systems in place to support safety or quality improvement including audits.

We asked the provider if they had a protocol for sharing information with patients’ GPs. The provider told us they had implemented a section on the patient registration form with the option for information to be shared with patients’ GPs. The provider told us that when patients consented, they shared information with the patient’s GP via email or letter. However, there was no evidence to support this.

There was no formal, standardised referral process to GPs or other external clinicians to maintain patient safety, including when patients were potentially at risk, including fertility and cancer patients.

Leaders were not able to demonstrate that safeguarding was being managed safely. The provider was not able to articulate the contents of the new safeguarding policy, dated 25 May 2024, and what may constitute a safeguarding concern. This presented a risk of harm to patients that the provider did not work to their own policy, and had a lack of understanding of safeguarding concerns that may require referral to external agencies. There was no formal process for the provider to review patients who may require referral to a safeguarding team. We first asked the provider to improve processes for safeguarding in 2020, and there has been insufficient improvement since then, which shows a continued lack of urgency to resolve issues identified by the CQC and improve services to vulnerable patients. This put patients at risk of harm.

Since the last inspection, the provider had not sufficiently improved or developed safeguarding processes in order to protect patients from harm. When patients were identified as survivors of female genital mutilation (FGM), the provider could not demonstrate that they worked to their clinic policy. There were 2 FGM flowcharts: an in-house flowchart and the local authority flowchart, which were not aligned. There was no clear guidance on which was followed.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Leaders were not able to demonstrate safe and effective staffing procedures. Since the last inspection, the provider had not carried out a risk assessment of performing surgical procedures without any other trained medical staff available. The provider used a healthcare assistant (HCA) to assist, and there was no risk assessment, policy, training packages or competency frameworks to support this decision. This was not in line with national guidance (Association for Perioperative Practice (AFPP)). The provider was not able to articulate an understanding of the risks associated with this, or how an emergency situation would be managed safely. There were no permanent staff at the service that could provide oversight of policies and operational governance, and no temporary cover arrangements were in place until a service manager was appointed. There were no formalised workforce plans in place at the service for the number of staff. The service was not able to provide protocols for how staff were being recruited, trained, or utilised at the service.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.