3 The Beeches

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question as requires improvement. The service was in breach of Regulation 15 in relation to risk assessment and maintenance of the building, and first aid arrangements. The service had made improvements and was no longer in breach of this regulation. The building was now appropriately risk assessed and any areas of concern were addressed promptly. There were now appropriate first aid arrangements in place. 

At this inspection the rating has remained as requires improvement. This meant some aspects of the service were not always safe. The service was in breach of Regulation 18 in relation to staff not having the appropriate level of safeguarding training. However, staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked with other agencies to do so. The service used systems and processes to safely prescribe medicines. The service managed patient safety incidents well. The building was safe, clean, well-furnished and maintained, and fit for purpose.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. 

There had been no serious incidents in the 12 months prior to our inspection. There had been 2 low-level incidents, but there were no themes from these. There had been no accidents in the service. 

All staff we spoke with knew what incidents to report and how to report them. Staff were familiar with the incident reporting process, although they told us that incidents were rare. They knew how to report and record any incidents on the service’s online incident reporting system. All concerns including incidents were logged on the online system. A manager would see the staff member who reported the incident the same or next day. The service had an incident/accident tracker to monitor the progress of reviewing and taking any action following incidents. 

Staff understood the duty of candour. The service had a duty of candour policy. There had been no incidents subject to the duty of candour.

Staff received feedback from investigation of incidents, both internal and external to the service. Any incidents were followed up and discussed in clinical governance meetings, which was then shared with staff.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. 

Staff were clear about the referral and assessment process. Most patients self-referred or were referred by their parents. Administration staff explained the process and costs to the patient or parent. Following pre-screening, staff analysed the findings and arranged a feedback session with a clinical member of staff. Prior to assessment, patients were required to submit physical healthcare information from their GP. 

Staff involved all the necessary healthcare services to ensure patients had continuity of safe care, both within the service and post-discharge. The service encouraged shared care with a GP where possible. Shared care is when a GP prescribes medicines that have been initiated by the service.

The provider has a small substance misuse element to its service. This was for people who have received an attention deficit hyperactivity disorder (ADHD) diagnosis and had problems with alcohol. They provided medicines and psychosocial interventions including cognitive behavioural therapy (CBT) approaches and motivational interviewing, for people with moderate levels of alcohol use. They prescribed medicines to support patients to reduce or abstain from alcohol but did not provide a detoxification programme. Staff told us that if a patient required more intensive support or detoxification from substances, they would signpost them to dedicated substance misuse services. 

We scored the service as 2. The evidence showed some shortfalls. Staff had not all completed safeguarding training to the appropriate level for their role. However, the service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff knew how to make a safeguarding referral, and did so when necessary. Staff were familiar with the safeguarding process, knew who to go to for advice, and how to raise and escalate any concerns. However, although all staff had completed safeguarding training, this was not always at an appropriate level in accordance with national guidance.  A manager was the safeguarding lead and had completed level 3 safeguarding training. The provider required all other staff to complete only safeguarding awareness training. National guidance states that all clinical staff who have contact with patients (adults or children) should have level 3 training and all administrative or non-clinical staff who have contact with patients (adults or children) should have level 2 training. This was a breach of Regulation 18: staffing.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Patients were risk assessed and asked if they wanted a chaperone. If this was required patients were encouraged to bring someone with them, but if necessary a member of the administration team could support them. Staff were aware of potential concerns regarding diversion, where medicines prescribed for one person were given to others, and where there were repeated ‘lost’ prescriptions.

Staff knew how to identify adults and children at risk of, or suffering from, significant harm. This included working in partnership with other agencies. Staff gave examples of when there had been safeguarding concerns and they had referred these to the local authority and liaised with other organisations such as schools. All safeguarding concerns and referrals were documented on the electronic care record. Decisions to refer safeguarding concerns to the local authority were discussed by the multidisciplinary team, but the final decision was usually made by the medical director and manager. There had been low numbers of referrals in the 12 months prior to the inspection.

Staff followed safe procedures for children using the service. Staff told us that they had a family approach to assessment. As such, children and young people were always required to have a parent or guardian with them, including 16 and 17 year olds. However, the clinician usually met with just the child or young person at the beginning or end of each session, so that they had the opportunity to talk away from their parent or guardian. 

Mental Capacity Act

The provider had policies and procedures to ensure that patients or their parents could give informed consent, and where applicable, followed the Mental Capacity Act. Staff recorded capacity and consent in the care records. Staff were aware of these policies and procedures. 

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis, usually in relation to medicines. 

If a patient lacked capacity or was too young to make decisions for themselves the staff would work with others in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. Staff were aware of the policy and had access to it.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff were aware of the risk assessment process. The 10 care records we reviewed contained appropriate risk assessments which included ongoing assurance around physical health to ensure that it was safe to continue to prescribe medicines. They also took account of potential mental health risks, in the context of the nature of the service. 

Staff involved patients in care planning and risk assessment. We reviewed 10 care records, which showed that patients or their parents were involved in their care. 

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was provided in a 3-storey office building, situated in a small business block in a residential area. Patients were seen on the ground and top floors. There was no lift, but there was level access and a disabled toilet on the ground floor for people with mobility issues or wheelchair users. The building had air conditioning, so maintained a pleasant ambient temperature all year round. 

Patients were seen on site. Diagnostic interviews were usually carried out remotely, but the final assessment and consultation was usually face-to-face. Face-to-face treatment reviews were available, although most patients chose to have them remotely. No physical assessments or clinical procedures were carried out on site. Staff acknowledged that space was limited, and there was no reception or waiting area. Patients were made aware of this when booking appointments and told that they could wait in their cars outside until their appointment. There was dedicated parking outside the building. Staff carefully managed bookings so that there was minimal overlap between appointments.

The provider had policies and logs for the safety, maintenance and general upkeep of the building. These were routinely monitored through the governance processes. Managers carried out regular ‘walkarounds’ of the building, to check for any issues.

Staff now carried out regular risk assessments of the environment. The service had a programme of building risk assessments. This ranged from staff undertaking weekly or monthly checks (such as for fire or infection control), to annual audits or specialist assessments (such as of electric systems or appliance testing). 

All staff who worked in the building had completed fire training. Fire extinguishers and fire blankets were situated in appropriate areas. Fire alarms were maintained and in accessible areas. 

The service now had appropriate first aid arrangements. First aid boxes, which were routinely checked, were available in the staff office and there were assigned first aiders. 

The service now had a maintenance log where staff identified issues and recorded actions that had been taken. The log showed that issues were usually addressed quickly, such as replacement of lightbulbs. There was one outstanding item, which could not yet be fixed as they were waiting on the delivery of a replacement part, but this did not impact on patients. 

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure staff received effective support, supervision and training. However, the service made sure there were enough qualified, skilled and experienced staff. They worked well together to provide safe care that met people’s individual needs.

The service employed 9 permanent staff (4 clinical staff including a consultant psychiatrist, registered nurses and a psychologist, a clinic manager and 4 administration staff). The service contracted other healthcare professionals (including doctors, nurse and pharmacist non-medical prescribers) on a sessional basis. Managers told us they had enough skilled and experienced staff to deliver the service. There were no vacancies, but the service was in the process of onboarding and inducting several new staff. Not all staff carried out a CQC-regulated service. 

Staff sickness levels had not impacted on patients. When sickness did occur, cover was managed within the service. 

Staff had received and were mostly up to date with appropriate mandatory training. All staff had completed their mandatory training. However, not all staff had completed the necessary level of safeguarding training for their role. The provider’s list of mandatory training did not include training in interacting with autistic people and people with a learning disability, that met or exceeded the recently published standards contained within the Oliver McGowan Code of Practice, which should include attending face-to-face training co-produced by people with lived experience. The provider had added this to their mandatory training schedule and had a detailed plan to ensure that all staff received this appropriate mandatory training in the near future in line with their job role. 

Staff received inhouse training on diagnostic interviews for attention deficit hyperactivity disorder (ADHD), using an adapted version of a recognised tool. Staff were observed using this in practice before they were signed off as competent. 

The provider used an external company to ensure employment policies were up to date and to manage recruitment. This included an employment handbook for staff, online training and the recruitment process included references and Disclosure and Barring Service (DBS) checks. Training, supervision and appraisal were recorded on the system, which all staff could access. All staff had had an appraisal. 

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean, tidy and well-maintained. The building was cleaned daily, which included an antibacterial wipe-down of frequently-touched surfaces.

The service had policies and procedures for the management of infection prevention and control (IPC). Managers had a contact at the UK Health Security Agency (UKHSA) who they could go to for advice. 

Staff adhered to infection control principles, including handwashing. Staff had all completed IPC training and were aware of the service’s policies. There were handwashing signs and gels throughout the service. 

The patient and staff group were at a relatively low risk of infection, as no clinical procedures or physical interventions were carried out onsite. Staff often worked from home and met with patients virtually. When patients were seen face to face this was in an office environment. There were policies for staff who worked in the building, which included when they could return to work following an infection. 

The service had contracts for the collection and disposal of general and sanitary waste. There was no clinical waste or sharps generated by the service.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management and did this in line with national guidance. No medicines were stored on site.

There was a process for the safe management and issuing of prescriptions. Prescription pads were stored securely. Boxes of prescription pads and individual prescriptions all had serial numbers which were logged and tracked. Prescriptions were audited, and the service had never had any missing prescription paperwork. Prescriptions were usually sent directly to patients, or to an online pharmacist that the service had vetted.

Staff reviewed the effects of medicines on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance. The service had an attention deficit hyperactivity disorder (ADHD) treatment pathway. Patients had a detailed assessment and had to meet diagnostic criteria in line with NICE guidance before a prescription was issued. Patients had the necessary health checks including cardiac risk scores. If there was a specific cardiac concern, patients would be required to have an electrocardiogram (ECG). There was a detailed consent process and risk assessment carried out before medicines were prescribed. Prescribing was carried out by the doctor and non-medical prescriber(s). Patients were usually seen (virtually or face to face) every 4 weeks, and a repeat prescription was usually completed then. Staff considered the prescribing rationale based on each individual patient, such as age and medical history, as well as any other medicines they were taking.

The service had a safer prescribing board, that was both a checklist and a tracker for each stage of the prescribing process. This had to be completed before a patient was added to the prescribing list, which was double-checked by administration staff and the clinician. Staff carried out audits of the prescribing process and routinely reviewed the safer prescribing board to check for gaps or delays, for example if they were still waiting for an ECG for a patient. There was a dashboard for monitoring repeat prescriptions. 

Staff told us the prescribing process generally worked well. Prescriptions were posted to patients, and there were sometimes problems with deliveries, which they monitored with the courier companies. 

Staff ensured that the safer prescribing protocol was followed before any prescriptions were issued. This included a medical history review, a cardiovascular risk assessment, mandatory physical health observations, an addiction risk and diversion assessment, and a discussion about shared care. Once medicines were approved and prescribed, there was a clear titration and review schedule which included monitoring or physical observations. Once the patient’s dosage was stable, typically after 6 months, preparations were made to transfer to shared care with a GP. The provider told us that there had recently been an increase in GPs declining shared care agreements. 

If shared care was agreed, there was a handover process, but the person would still be reviewed either 6 monthly or annually depending on the patient. An annual review was a comprehensive assessment that included the physical health of patient and discussion about their life and risk assessment. Patients can contact the service between reviews. If shared care is not agreed, patients can look to find a GP who will accept this or continue to have medicines from the service.

There had been some national ADHD medicines shortages, but the service managed this and changed patients over to different medicines where appropriate.