Sapphire Clinics (London) Limited Also known as Curaleaf 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 rated the service as good for providing a Safe service. As part of this assessment, we looked at 7 quality statements for the key question of safe. Learning from the investigations was shared with staff and systems and processes reviewed and developed to improve services. People were involved in discussions about their care. However, we were not assured that patients were always fully informed each time when consenting to treatment as treatment agreements were signed prior to initial consultations. Leaders employed staff with a range of skills and specialist backgrounds including mental health. There were sufficient staffing levels and oversight to ensure people’s needs were being met.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders had a proactive approach to patient safety. Staff had access to the incident reporting system and were encouraged to report all incidents for shared learning opportunities. Leaders told us there was a culture of safety and learning which was based on openness, transparency and learning from events. They shared an incident with us where they had implemented a change on their electronic prescribing system following an incident where there had been a mistake and the incorrect oil had been prescribed. Staff also told us that patients were able to report adverse events through a bespoke mechanism on their online account.

Processes were in place to look at incidents and complaints and put actions in place to help mitigate risks in the future. The incidents policy was contained in the staff handbook and there were online forms for staff to complete. The incident and complaints logs were systematically reviewed and updated with closure dates for all actions, ensuring thorough documentation and resolution. The provider had also introduced a weekly complaint meeting to ensure they identified and addressed themes efficiently.

We noted themes from incidents and complaints were discussed in Operations, Compliance, Pharmacists, and Multi-Disciplinary Team (MDT) meetings, which are attended by clinicians from different backgrounds, to ensure comprehensive dissemination and understanding among all staff members. The provider also had a risk register in place that combined identified actions and set a plan for improvement, providing a structured approach to mitigating risks.

Staff and leaders told us safety and continuity of care is a priority throughout people’s care journey. This happens through a collaborative, joined-up approach to safety that involves the patient along with staff and other partners in their care such as their NHS GP. This includes referrals, admissions and discharge, and where people are moving between services. Leaders also told us they take part in best interest meetings and MDT meetings with other services as required to discuss care of their patients. We saw MDT notes to confirm this.

The provider’s electronic health record system had safeguards in place to ensure there was communication with other healthcare professionals and services for every patient. People could not have a consultation to join the clinic until the provider had received their summary of care records from their NHS GP. The clinic also would need to receive discharge letters from previous clinics when patients transfer, to mitigate possible risk of duplicate prescribing from other clinics.

The provider also had access to an NHS Login which had improved the patient pathway by allowing them to view, with the patient’s consent, complete and up to date GP records. Once a patient has been approved by the MDT for treatment, the provider would send a letter to their NHS GP to inform them about the treatment and a letter is sent after every appointment. Their system is directly linked to patient records.

All staff we spoke with were aware of their responsibilities in reporting concerns and we found they had a clear understanding of safeguarding, and the appropriate training was in place. Leaders told us they documented capacity to consent to treatment at the beginning of the care journey and that they had discussions about capacity to consent to treatment at their MDT meetings. We saw examples of patients who lacked capacity to consent to treatment, where best interest meetings had been held with key stakeholders including parents, social workers, care home workers, and GPs.

All staff had completed Safeguarding training and there was a designated safeguarding lead to handle and escalate any safeguarding concerns promptly and effectively.

Clinical risk training including self-harm and suicide prevention and was delivered to the non-medical prescribing team on a 6-monthly basis to capture new staff. The provider had also enabled ‘Live Chat’ and email options to so that patients could communicate with them in a way that suits their needs if they were unable to speak openly.

Staff and leaders told us people were informed about any risks and how to keep themselves safe when they were accepted by the clinic. For example, they would seek assurance from patients that they use their medicines as directed as per CBPMs legislation. This was evidenced through Treatment Agreements and appointment notes. They also provided information about risk in written form after each appointment. The provider also supported patients to source medically approved vaporisers. Clinical staff told us they routinely asked patients about driving and gave additional information if they drove. Patients were signposted to the portal for additional safety information about safe vaping and how to measure oils using the syringe provided.

The patient records system had clinical flags to highlight risk and vulnerable cases. Patients could also report adverse events through their app. We saw evidence that patients were signposted to other services such as mental health crisis support when needed. The provider made reasonable adjustments for patients with additional needs, for example using the chat function on Zoom during appointments for deaf patients, requesting non-child resistant packaging from the pharmacy for those with dexterity problems, or large print labels for those with visual impairments.

The leaders told us that neurodiverse patients had complained that the language used in communications wasn’t accessible. The clinic therefore carried out a review with a neurodiverse person and implemented the changes that were recommended. Staff told us that chaperones were available upon patient or clinician request

The clinic developed its own bespoke Android app so patients could easily access the portal, and patients could send a secure link via their app to their carer to attend appointments. Patients could access a cloud-based communications platform that allowed users to connect via video, audio, phone, and chat via the app making it easier for them and a secure link. If the connection failed clinicians could call the patient via another platform and this was recorded on the consultation notes.

The leaders told us they had a dedicated human resources (HR) manager and an online on-boarding and appraisal system for staff. They said they held weekly operational and capacity meetings and a monthly recruitment meeting with HR and the management team to ensure that their short and long-term staff projections were aligned and appropriate. They said this was frequently adjusted to ensure they offered the highest level of service to their patients. Staff received training appropriate and relevant to their role and they had developed a specific CBPM training program for all their staff. Staff told us the staffing level was sufficient. They said the team was expanding as the clinic took on more patients and was sufficient to cover staff sickness and holidays. There was a rota for staff to see who was on what responsibility such as phones, live chats and the rota would be rearranged if needed. There was a clear organisational chart where every staff member knew who their direct line manager was and to whom to escalate complaints.

The clinic had an Applicant Tracking System within their HR platform that allowed HR and leaders of various functions to oversee the selection criteria and process, ensuring transparency and fairness. Additionally, HR provided all new managers responsible for recruitment with training on ethical recruiting practices.

There were specific training programs for each section of staffing including an intensive clinical training program for all new starters. This included online modules on cannabis basic science, prescribing and one to one sessions with various departments. There was then a period of supervision for the initial 3 months for all new clinicians, monthly checks-ins with the medical director who was also available for the discussion of complex patients when needed.

All staff had an annual appraisal and there was a recognition system for staff who had demonstrated the clinic’s values.

All staff completed annual mandatory training.

The leaders told us that, although they have not had any face-to-face appointments for a few years as they have all been virtual, they have an infection prevention and control policy for their registered location and all staff complete training relevant to their role.

The infection prevention and control policy was in line with national guidance and was updated annually. Infection control training was undertaken by all clinical staff and there was an infection control lead.

Patients had access to a portal with information about CBPMs. Patients were able to track where their prescription was and when they would receive their medicines from the pharmacy. The service used treatment goals and patient reported outcome measures to help determine effectiveness of treatment. These were reviewed at each consultation to ensure ongoing efficacy and appropriateness of treatment. People were involved in discussions about their care. However, we were not assured that patients were always fully informed each time when consenting to treatment as treatment agreements were signed prior to initial consultations only. Discussions of consent to treatment (including risks) was not always recorded in the records we reviewed

Prescribing staff in the service spoke positively about the culture and the support of leaders and other prescribers. They told us they received relevant training that allowed them to safely carry out their role. Leaders ensured that staff were trained and assessed as competent to carry out their role through the delivery of a set training schedule and observations. Leaders told us they employed pharmacists with specialist backgrounds in mental health conditions to help support non-specialist staff in caring for patients with mental health conditions. Non-specialist prescribing staff told us that they were able to refer patients back to their specialist prescribers. They told us they were able to easily contact specialists with any queries they had. Staff told us they were given enough time to review patients’ histories when prescribing for repeat prescriptions. They had access to relevant patient histories held in patient records when prescribing. Staff and leaders spoke about how they aimed to promote deprescribing of CBPMs in patients to help improve patient outcomes. They showed us examples where this had occurred.

The service had a process where non-specialist prescribers would prescribe cannabis-based products for medicinal use (CBPMs) on an ongoing basis for patients. Criteria for referral to non-specialist prescribers was not patient specific. Non-specialist prescribers were given guidance when they should refer back to the specialist prescriber.

We saw instances where patients were moved onto shared care immediately after the initial consultation. This was not in line with the service’s policy where patients would only move onto shared care once they were stable and were responding to treatment.

We were not assured that specialist prescribers retained effective oversight of patients under their care as there were no set review dates with specialists. We raised this with the service. They informed us that they had recently introduced a new process where the specialist prescriber was sent notes of each consultation with non-specialist prescribers and patients would be offered routine annual reviews with their specialist.

The service had a process for ensuring patients were eligible for the service and ensured they had access to relevant patients’ medical histories including information from GPs and other specialist prescribers. Patients were discussed at team meetings with relevant specialists before being accepted into the service.

Prescriptions and treatments were initiated by a specialist doctor where an unmet clinical need was identified, in line with current legislation.

Information was shared with patients’ regular GPs. We saw patients’ GPs were sent consultation notes after each consultation. The service also offered learning materials to GPs with limited knowledge on the use of CBPMs.

The service had a process for actioning patient safety alerts.

The service conducted clinical audits to drive improvement within the service. We saw actions and learning taken from the most recent audit completed in February 2024.

Medicines incidents were recorded and analysed.