Cognacity

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• 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.

This is our first inspection of the service. This key question has been rated inadequate.

The service was in breach of Regulation 12 Safe care and treatment and Regulation 13 Safeguarding service users from abuse and improper treatment. The provider had not established effective systems to ensure that care and treatment was provided safely and that people using the service were safeguarded from abuse and improper treatment.

This meant people were not safe and were at risk of avoidable harm.

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 service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Although 90% of staff had completed the mandatory training in incident and accident reporting, staff did not know how to identify incidents or report them appropriately. We reviewed the service incident log. One incident was reported in the past 12 months. It involved a patient’s prescription posted to another patient’s home in error. The incident record did not capture the details of patients or staff involved. No investigation was completed and no learning recorded to prevent a future occurrence.

The service did not record all the incidents that were reported. An incident involving missing controlled prescription stationery occurred in June 2025, but it was not recorded as an incident. Additionally, staff had not followed the provider’s medicines management policy, which set out other actions to take.

The provider had a serious untoward incident policy and an incident reporting form. However, the policy did not detail key information such as near misses, incident categories, severity or impact, and contained inaccurate information about statutory notification requirements. Leaders told us that their expectation was usually for managers to complete the incident form on behalf of staff.

The minutes of meetings we reviewed did not demonstrate that staff discussed learning from incidents, either internal or external to the service. We saw no evidence of changes made as a result of such learning. Staff we spoke with were not able to share examples of recent learning from incidents. This created the risk of avoidable harm from risks identified in past incidents which were not responded to and mitigated against appropriately.

The service also kept an accident log. Two accidents involving patients experiencing ill health on the service premises were reported during the same period. These records were similarly limited, missing key details such as patient and staff identifiers, or any learning.

The duty of candour is a statutory duty that requires registered providers to act in an open and transparent way with people receiving care or treatment and includes specific requirements for certain notifiable safety incidents. The provider’s serious incident policy did not outline the duty of candour requirements, nor was duty of candour part of mandatory staff training. We did not see the duty of candour being considered in the incident records we viewed.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

The service received referrals from self-funding patients. People could self-refer or be referred by their carers, medical insurance providers, employers and other organisations.

The admission process did not always ensure that essential information about the patient was received. The referral coordinator, who was part of the administrative team, dealt with incoming referrals. The service did not have an admission protocol or clear inclusion and exclusion criteria that it considered against each referral. However, staff told us that referrals would be discussed with one of the doctors to determine if the patient’s needs could be met safely.

Staff did not involve all the necessary healthcare services to ensure patients had continuity of safe care, both within the service and post-discharge. The provider’s policy did not reflect current guidance on obtaining and sharing all relevant information with the patient’s GP. Leaders told us it was not the policy or practice to obtain patients’ medical history before commencing treatment. Instead, the service relied on information reported by the patient or carer. This meant that all healthcare staff involved in patient care were not aware of their changing physical health needs, allergies or potential drug interactions, and that clinical decisions were not always safe.

The provider did not have protocols outlining the treatments offered, their pathways or protocols for risk escalation, for example situations when patients must be seen face-to-face. This meant there was no clear guidance for staff to refer to. Although leaders told us that staff would discuss individual cases with clinicians who made the final decisions, this process was informal and created the risk of inconsistency. However, the service provided information to patients explaining that their initial appointment for attention deficit hyperactivity disorder (ADHD) or autism assessment would be in person.

The provider had no written guidance for staff on discharging patients, missed appointments (DNA) or unexpected exits from treatment. Although some staff we spoke with explained what actions they would take, for example send a discharge letter, there was limited assurance of consistency. In one record we viewed, a patient had disengaged from treatment for several years, with no follow-up or reason documented. In another case, the leaders told us the patient had been discharged, however there was no record documenting this on the provider’s electronic system.

However, some systems worked more effectively. The service had a process to establish shared care arrangements for ADHD with primary care. In 6 care records we viewed, there was evidence of doctors sharing information with the patients’ GPs appropriately.

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 in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Although 94% of staff had been trained in safeguarding to the level in line with their role, the provider had not embedded robust systems to safeguard people.

Whilst the service had a safeguarding policy, it did not specify frequency of refresher training for staff or training requirements for the safeguarding lead. The policy advised that all staff were to complete level 1 safeguarding adults training, however the training records showed approximately half of staff as exempt from this training and majority had completed level 2 training instead.

There were no meetings where safeguarding was regularly discussed. Although the service held a quarterly quality assurance and governance meeting, safeguarding was not on its agenda. We viewed the minutes of a doctors’ peer group held in May 2025. A doctor brought a case for discussion, which the group thought presented a safeguarding risk. However, no patient identifier was recorded, and it was not clear what, if any, follow-up actions were taken.

We reviewed the service’s safeguarding log. Two safeguarding cases were recorded in 2024 and 2025 respectively. These records were limited and missed key details, such as dates and actions taken. It was not clear if the cases had been closed. We reviewed the care records for 2 above patients. Although referrals were made to the local authorities in both cases, there was no evidence of active follow-up or joint working with other agencies. We discussed above cases with the service’s safeguarding lead, who told us that there had been no learning from those.

We reviewed the safeguarding audit completed by the service in March 2025. This consisted of an overview of the organisation’s procedures and activities related to safeguarding. One of the actions it identified was for an audit to be arranged at the next clinical governance meeting, however no date for this was specified. We did not see evidence of this being completed, nor discussed in the meeting minutes we reviewed. Safeguarding was not on the provider’s audit schedule.

However, the service had a safeguarding lead who was easily accessible to staff.

The service did not always work well with people to understand and manage risks. They 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.

We reviewed 10 care and treatment records. For 3 patients, no risk assessments or any other records were kept on the provider’s electronic record system. There were no regular meetings where staff discussed patient risks. No audits of risk assessments took place.

The service offered treatment for substance misuse including opioid substitute treatment (OST), however the leaders demonstrated a lack of knowledge around managing risks specific to it. The provider had not ensured that staff risk-assessed dispensing arrangements, considered safe storage of medications that may cause serious harm if accidentally ingested by children, or that Naloxone was supplied to those at risk of experiencing or witnessing an opioid overdose. Naloxone is a life-saving medication used to rapidly reverse an opioid overdose. This increased the risk of avoidable harm within this patient group.

Of the remaining 7 care and treatment records we reviewed, each contained risk assessments that were completed and updated throughout treatment, for example in response to changes in the patient’s mental health or prescribed medications.

We saw evidence that staff involved patients in the completion of their risk assessments and care plans. The records reflected conversations with patients.

We spoke with 8 patients and 5 carers of patients using the service. Most said they felt involved in reviewing their care and treatment, and had access to the care plan. One carer said: “We are very much part of the meetings with the doctor”.

The service had a dedicated helpline available to patients for emergencies out of hours. Most patients and carers said staff had provided them with information on it.

Staff communicated with patients so that they understood their care and treatment. Staff had access to an interpreter service.

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

Staff did not complete environmental risk assessments consistently. The health and safety risk assessment was due in August 2025; fire risk assessment in January 2025; portable appliance testing (PAT) in November 2024; and fire extinguisher service in August 2025. There were some outstanding actions identified in 2023 in the legionella risk assessment. We raised above with the leaders, who told us that all these would be renewed in October 2025.

We found considerable gaps in the weekly fire alarm test records. The records were missing for 2 weeks in February 2025, 2 weeks in March, 3 weeks in May, 1 week in June, 2 weeks in July and 2 weeks in August. There were no records for April 2025. Additionally, staff only tested the call point on the ground floor but no other points in the building. This meant staff may not have been sufficiently aware of potential faults in the system.

The premises were equipped with a defibrillator and first aid boxes were easily accessible. However, the used plasters in the first aid box in the staff room needed replacing.

There was no dedicated clinic room and no drugs were kept on the premises. Staff used clinical equipment including weighing scales, blood pressure monitors and a handheld electrocardiogram (ECG) monitor, however there was no system to ensure these were checked or maintained. This meant the provider could not be assured they produced accurate readings.

The training records showed that 100% of staff had completed the mandatory health and 98% safety and fire safety awareness training. The service environment appeared well-maintained and well-furnished.

Staff had easy access to panic alarms which were integrated into the provider’s electronic system. CCTV was in use in communal areas. Staff told us they felt safe using the premises. However, some staff shared their concerns about the staircase in the building, which they thought was not safe due to being steep and narrow.

Patient and carer feedback about the care environment was positive. They described it as clean, comfortable and “really nice”, although some people could not comment as they had only attended online consultations.

Although the provider made sure there were enough qualified, skilled and experienced staff who received regular appraisal and training, they did not ensure that all staff received supervision and did not outline clear expectations around induction and training. Staff did not always work together effectively to provide safe care that met people’s individual needs.

The service team had been stable, with no leavers and 1 new starter in the past 12 months. Staff absence rate was minimal and there was no agency use.

Patients and carers we spoke with told us that staff were always available, and that appointments were rarely, if ever, cancelled. Staff also said the service was adequately staffed.

The multidisciplinary team (MDT) included a range of roles that met the needs of the patient group. It comprised psychiatrists, psychologists, therapists, managers and administrative staff. The team was a combination of directly employed staff and self-employed doctors working for the provider part-time under practising privileges.

The service had appropriate systems for safe recruitment of staff. This included criminal record and right to work checks, and where relevant, evidence of continued professional registration and indemnity arrangements. Managers monitored the completion and renewals of these.

Managers provided new staff with induction to the service. Staff we spoke with said they received an induction. However, the dates of induction completion were not recorded. The provider’s policies did not specify expectations around this, and we observed some inconsistencies. The induction programme for psychiatrists did not specify a timeframe for completion.

The provider’s policies did not specify how often staff were required to refresh mandatory training or the levels of training required for different staff groups. Although the training records showed 95% of staff as up-to-date with mandatory training, it was not clear what guidance the managers used to determine this and how staff knew the individual training requirements.

The training programme was appropriate for the patient group using the service. Staff could attend specialist training relevant to their role, for example on neurofeedback and schema therapy.

Clinical staff could access peer groups, continued professional development (CPD) and external clinical supervision. However, other staff, including the registered manager, did not receive supervision, despite their direct contact with patients. The provider had no supervision policy in place. This meant that managers may not be able to identify support needs or poor performance and deal with it promptly and effectively.

Although some staff told us they worked closely with others, others shared concerns about the lack of adequate forums for MDT discussions. Some meetings were held monthly, bi-monthly and quarterly, however were not attended by all staff. This meant staff had limited opportunities to discuss patient risks, to reflect on and learn from practice, and for personal support and professional development.

The service had adequate medical cover and a procedure for medical emergencies. Staff were trained in basic life support, with 92% having completed this mandatory training. The service had an out-of-hours helpline available to patients.

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

Staff did not follow infection control principles. Staff did not record if clinical equipment was cleaned and did not undertake audits in this area. The clinical equipment was stored in reception office. Leaders explained that doctors cleaned it before and after each use using cleaning wipes kept with the equipment. However, we observed a doctor collecting a blood pressure monitor from reception without cleaning it first. This meant the provider could not be assured that equipment used on patients was clean.

Physical examinations took place in consulting rooms. However, the rooms we viewed did not have handwashing facilities, and the service did not have body fluid spillage kits.

However, the care environment appeared visibly clean, had good furnishings and was well-maintained.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, staff provided information to patients about their medicines and discussed changes to those.

The provider did not have effective systems to ensure medicines were prescribed safely, and prescribing practices did not reflect the national guidance. The service did not keep appropriate care and treatment records, meaning those patients’ risks and needs were not known.

We viewed 20 prescribing and care and treatment records in total.

We did not see that comprehensive assessments, evidence-based treatment plans and risk assessments were consistently carried out when prescribing medicines and treatments for patients. We found that a patient was prescribed medicines for unlicenced indication, or outside the product licences, known as ‘off label’ use. There were no clinical records available for this patient, apart from copies of prescriptions issued. The Department of Health and Social Care (DHSC) guidance states that if deciding to deviate from licensed medicines, clinicians must be prepared to justify their clinical decisions and keep comprehensive contemporaneous notes to support their decisions. To obtain an informed consent requires staff to discuss relevant issues, including the evidential basis of treatments, with the patient. Additionally, this was not in line with the provider’s own policy which set out the requirement for each clinician to add a record on the electronic record system within 48 hours of the consultation. We raised this with leaders who told us that staff were in the process of adding the consultation notes for this patient to the system.

Prescribers did not consistently liaise with patients’ GPs and other healthcare professionals with regards to treatment provision. In 7 records we reviewed, prescribers had not obtained consent to contact patients’ GPs, nor recorded that the risks of not doing so had been clearly discussed with the patient, however they continued to prescribe medicines to these patients. This meant that other healthcare professional involved in patients’ care were not aware of their changing physical health needs and potential drug interactions. This also created a risk of patients receiving more than one prescription from other services (double prescribing), greatly increasing the risk of avoidable harm.

In 2 records we saw that the doctor had prescribed up to 90 days of controlled drug (CD) medicines associated with dependence. The DHSC strongly recommends that prescriptions of such medicines are limited to the quantity necessary for up to 30 days’ treatment; exceptionally, to cover a justifiable clinical need and after consideration of any risk, a prescription can be issued for a longer period, but the reasons for the decision should be recorded on the patient’s notes. However, no consultation records for these 2 patients were available at the time of our inspection.

The service had not made records of patients’ dispensing pharmacies when prescribing opioid substitute treatment (OST). This meant staff would not be able to contact the pharmacy when appropriate, for example with concerns about the patient’s health or wellbeing or in the event of a hospital admission.

The provider had not maintained safe systems for storage and management of controlled prescription stationery. The system to manage void prescriptions (prescriptions that are not to be used for any reason) needed further improvement. The best practice guidance advises that voided prescriptions should be retained for local auditing purposes for a short period prior to being destroyed securely. However, we found a void prescription from May 2022. We also found a void prescription from June 2025 without a line through it, as recommended by the same guidance.

The service did not carry out regular and effective audits to identify areas for improvement and did not ensure that the necessary improvements took place in a timely manner. Leaders told us that 6-monthly CD audits were completed. However, we saw that one annual CD audit was completed in April 2025, covering the period from April 2024 to April 2025. The audit identified some actions, however outlined no clear timeframe, roles or responsibilities to monitor their completion.

An incident involving 11 missing controlled prescription forms occurred in June 2025. Although it was later reported to NHS England, it was not recorded on the service incident log. Staff had not followed the provider’s own medicines management policy, which set out actions to be taken in managing such incidents. We were additionally concerned that this policy did not reflect the current guidance. The provider’s policy stated that patients must report their own lost prescriptions to the police. This was not in line with the national guidance which sets out the expectation for organisations to have a system in place in the event that patients report lost prescription forms and to record these in the organisational incident reporting system. This meant the provider had limited oversight of incidents involving controlled stationery and did not share information with the relevant bodies. This increased the risk of avoidable harm due to misuse or diversion of controlled stationery items in the community.

However, most patients and carers we spoke with told us that staff explained their prescribed medications and side effects well and involved them in any changes. Patients and carers said they could speak with a prescriber when needed.