The Care Quality Commission
  • Doctor
  • Independent doctor

Lyphe Clinic

Overall: Good read more about inspection ratings

Unit 13, Farnborough Business Centre, Eelmoor Road, Farnborough, GU14 7XA (020) 4538 2273

Provided and run by:
Lyphe Clinic Ltd

All Inspections

28 & 29 September & 7 October 2022

During a routine inspection

This service is rated as Good overall. (Previous inspection March 2022 – Requires improvement)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out this announced focused inspection of The Medical Cannabis Clinic under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions and to follow up on breaches of regulation we identified in a compliance review in March 2022 and to follow up on information of concern that we had received. At the last inspection carried out in March 2022 we found they were not operating effective systems and processes to ensure good governance in accordance with the fundamental standards of care, in particular:

  • Individual care records did not always indicate what the patient was being treated for.

  • There were no details of discussion in Multi Disciplinary Team (MDT) meetings to demonstrate robustness of decision making.

  • The provider did not have effective processes in place to assess the competencies of all staff they employed in order to plan appropriate training and development.

  • We were not assured that the systems for reporting and following up on incidents were operating effectively.

  • The policies relating to medicines and prescribing of cannabis based medicinal products did not cover important operational aspects of the service and were not always followed.

At this inspection on 28 & 29 September and 7 October 2022 we carried out a full comprehensive inspection and found significant improvements had been made.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations

The Medical Cannabis Clinic provides medical treatment for patients focused around the use of Cannabis Based Products for Medicinal Use (CBPMs) by experienced medical staff working within the government guidelines.

The operations manager was the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We did not speak directly with patients during the inspection.

Our key findings were:

  • Significant improvements had been to the service which included recruitment of appropriately skilled staff and implementation of key systems and processes to ensure effective monitoring of care and treatment.
  • The provider had systems in place to protect people from avoidable harm and abuse.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • There was a clear vision to provide a safe, personalised, high quality service.
  • All staff we spoke to felt valued by the leaders and said there was a high level of staff support and engagement.
  • The systems for reporting and following up on incidents were operating effectively.
  • The policies relating to medicines and prescribing of cannabis based medicinal products covered important operational aspects of the service and were followed by all clinicians.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • The service had a business development strategy that effectively monitored the service provided to assure safety and patient satisfaction.

The areas where the provider should make improvements are:

  • Review all active patient records to ensure they contain a copy of relevant identification.
  • Implement a process to record and identify clinical outcomes for patients.
  • Continue to review information available for patients in relation to medicine delays.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

1 and 9 March 2022

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at The Medical Cannabis Clinic on 1 & 9 March 2022 ( Previous inspection May 2021 rated Good). Following this inspection it is rated as Requires Improvement overall.

We looked at three key questions and they are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services well-led? – Inadequate

We carried out this announced focused inspection of The Medical Cannabis Clinic under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions and to follow up on breaches of regulation we identified in a compliance review in May 2021 and to follow up on information of concern that we had received. At the inspection carried out in May 2021 we found they were not operating effective systems and processes to ensure good governance in accordance with the fundamental standards of care, in particular:

  • Some policies did not provide clear guidance to clinical staff such as the medicines management and the prescribing policy in relation to how consent is obtained and what information is given to patients about unlicensed drug use.
  • There was no formal recruitment and selection process for clinical staff and no skills assessment process for managerial staff.
  • The provider did not have a formal system for carrying out clinical audits and quality improvement.
  • Patients were not provided with clear information about external factors that may delay receipt of their medication

At this focused inspection on 1 & 9 March 2022 we looked at the domains of Safe, Effective and Well-led. We found that although some improvements had been made, we found further concerns and served Warning Notices on the provider in relation to breaches of Regulations 12 (Safe Care & Treatment) and Regulation 17 (Good Governance)

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations

The Medical Cannabis Clinic provides medical treatment for patients focused around the use of Cannabis Based Products for Medicinal Use (CBPMs) by experienced medical staff working within the government guidelines.

At the time of our inspection the provider was in the process of recruiting a registered manager and the head of operations was undertaking these duties. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We did not speak directly with patients during the inspection.

Our key findings were:

  • The provider had systems in place to protect people from avoidable harm and abuse.
  • All staff we spoke with felt valued by the leaders and said there was a high level of staff support and engagement.
  • Individual care records did not always indicate what the patient was being treated for.
  • There were no details of discussion in Multi Disciplinary Team (MDT) meetings to demonstrate robustness of decision making.
  • The provider did not have effective processes in place to assess the competencies of all staff they employed in order to plan appropriate training and development.
  • The policies relating to medicines and prescribing of cannabis based medicinal products did not cover important operational aspects of the service and were not always followed.
  • We found there was a lack of transparency with patients as regards pharmacy choice.
  • Clinical outcomes audits did not contain sufficient details about patient outcomes to provide an adequate evaluation of the treatments prescribed.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • There was a commitment and appetite to work with external partners to share learning and make the service as accessible as possible.
  • A nurse led aftercare support service had been launched to provide additional support to patients managing chronic pain. This has had some positive feedback from patients.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

5, 10, & 13 May 2021

During a routine inspection

We carried out an announced comprehensive inspection at The Medical Cannabis Clinic as part of our inspection programme.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out this announced first comprehensive inspection of The Medical Cannabis Clinic under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions and to follow up on breaches of regulation we identified in a compliance review in August 2020 following the receipt of information of concern. At that compliance review we found they were not operating effective systems or processes to ensure compliance with the requirements of the regulations as they were failing to assess, monitor and mitigate risks related to the quality and safety of the service, in particular:

  • We found that the systems for carrying out multidisciplinary team meetings (MDT) were not effective.
  • We found that the provider was failing to keep contemporaneous records in respect of each patient, including a record of the care and treatment provided and of decisions taken in relation to the care and treatment provided.
  • Several policies we reviewed, were not service specific.
  • The prescribing of cannabis-based products for medicinal use (CBPMs) was not in accordance with NICE guidance and the evidence base relied on for prescribing outside of these guidelines was not set out in your policies
  • The systems in place for maintaining oversight of clinician's training was ineffective.

We served a Warning Notice on the provider.

This inspection on 5,10 & 13 May 2021 found improvements had been made.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations

The Medical Cannabis Clinic provides medical treatment for patients focused around the use of CBPMs by experienced medical staff working within the government guidelines.

At the time of our inspection the provider was in the process of recruiting a registered manager and the head of operations was undertaking these duties. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We did not speak directly with patients during the inspection.

Our key findings were:

  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The provider had systems in place to protect people from avoidable harm and abuse.
  • There was a clear vision to provide a safe, personalised, high quality service.
  • Some policies did not provide clear guidance to clinical staff such as the medicines management and the prescribing policy.
  • There was no formal recruitment and selection process for clinical staff and no skills assessment process for managerial staff.
  • All staff we spoke to felt valued by the leaders and said there was a high level of staff support and engagement.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • The service had comprehensive business development strategy that effectively monitored the service provided to assure safety and patient satisfaction.
  • There was a commitment and appetite to work with external partners to share learning and make the service as accessible as possible.
  • Feedback about the practice was positive from patients

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care