Cognacity

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 assessment we rated this key question as inadequate. At this assessment the rating has changed to Good.

At our previous assessment we identified significant concerns regarding governance, safeguarding, incident management, environmental safety and medicines management.

At this assessment, we found the provider had made improvements and was no longer in breach of the previous warning notice. Systems for incident reporting, safeguarding, medicines management, environmental safety and admissions processes had strengthened.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our assessment in October 2025, we found significant shortfalls in incident reporting, learning and oversight. Staff did not consistently report incidents, learning was not routinely shared across the service, and the provider's policy did not adequately reflect the duty of candour requirements. At this assessment, we found the provider had addressed these concerns and met the requirements of the warning notice. However, further work was needed to ensure these improvements were fully implemented.

Systems for reporting, reviewing and learning from incidents had improved. Between November 2025 and May 2026, staff reported 22 incidents, including near misses, prescribing errors and record keeping issues. Staff understood what incidents to report and how to report them. In the 12 months before the assessment, the service recorded seven serious incidents, five of which were unexpected deaths that occurred after October 2025.

Staff understood and applied the duty of candour. They were open and transparent when things went wrong and provided patients and families with explanations and support. We saw evidence of communication with families following unexpected deaths, and the provider had updated its policy to reflect duty of candour requirements. Staff also received support and debriefs following serious incidents.

However, improvements were not yet fully embedded. Learning from incidents was not always shared consistently across the service and not all staff were aware of learning arising from serious incidents. For example, a learning bulletin relating to relapse prevention had not been circulated to staff. In addition, some incident records lacked sufficient detail. One incident involving a patient becoming unwell did not record any follow-up actions, limiting the provider's ability to demonstrate effective oversight, learning and improvement.

At our inspection in October 2025, we found the service did not always obtain sufficient information before accepting referrals. The provider had no formal admissions protocol and had not clearly defined the types of patients whose needs could be safely met by the service. At this assessment, we found these concerns had been addressed.

The service accepted referrals from self-funding patients, as well as referrals from carers, medical insurers, employers and other organisations.

The provider had implemented a formal admissions and exclusions policy that included clear eligibility criteria and identified circumstances where treatment would not be appropriate, such as active substance dependence requiring detoxification or high-risk mental health needs requiring inpatient care. The policy also provided guidance on when patients should be seen virtually or face-to-face. This supported more consistent decision-making and helped ensure people were referred to the most appropriate service.

Staff worked effectively with healthcare and social care professionals to support continuity of care during treatment and following discharge. Since the last inspection, the provider had strengthened its approach to GP communication. Patients were asked to consent to information sharing before treatment commenced and staff followed a clear process where consent was not provided. This supported safer and more coordinated care.

At our inspection in October 2025, we identified significant concerns regarding safeguarding arrangements. Staff training was not always up to date, safeguarding policies were incomplete, there was limited engagement with external agencies and safeguarding activity was not routinely monitored. At this assessment, we found the provider had taken action to address these concerns.

Staff had completed safeguarding training appropriate to their role and understood their responsibilities for identifying and reporting safeguarding concerns. Most staff were up to date with their safeguarding training, and the safeguarding lead had completed additional Prevent training.

Following the previous inspection, the provider appointed a safeguarding lead to provide advice and oversight. A safeguarding register was introduced to record, monitor and review safeguarding concerns. Since February 2026, the service had recorded five safeguarding incidents, including concerns relating to historical sexual abuse, suicidal ideation, safeguarding children and risks posed by third parties.

Staff knew how to make safeguarding referrals and provided examples of occasions when they had done so appropriately. They understood how to identify adults and children at risk of abuse or neglect and recognised the importance of working with partner agencies to protect people from harm. Staff regularly sought advice from local authority safeguarding teams where concerns were identified.

Staff and leaders could describe learning from safeguarding incidents, including the importance of making direct referrals to children's social care services when required.

Staff understood how to protect people from harassment, discrimination and abuse, including those with protected characteristics.

Some areas for additional strengthening were identified, for example, the safeguarding lead provided supervision and support to staff but was not receiving formal safeguarding supervision themselves. This limited independent oversight and support for the safeguarding lead role.

At our inspection in October 2025, we found the service did not consistently assess and manage risks. Risk assessments were not always completed, and staff did not safely manage the risks associated with opioid substitution treatment (OST). At this assessment, we found improvements had been made. However, further work was required to ensure risk management arrangements were fully embedded and consistently documented.

We reviewed 15 risk assessments and associated risk management plans. Staff were identifying and managing risks; however, documentation was not always sufficiently detailed, timely, or consistent. Patients receiving medical treatment were expected to have a documented risk summary completed as part of their assessment. In 5 of the 15 records reviewed, risks had either not been documented promptly following assessment, or evidence of risk management was recorded across email correspondence and informal case notes rather than within a clear, structured risk assessment.

For example, one patient's records showed a history of self-harm. While this risk had been identified, it was not clearly reflected within the initial risk assessment. A comprehensive risk formulation was not completed until the patient's ADHD assessment six weeks later. Information relating to risk from the initial assessment was contained within informal notes on the system, and there was no crisis plan recorded. This reduced assurances that all identified risks and mitigating actions were consistently documented, accessible, and subject to effective oversight.

Risk assessments were generally more comprehensive for patients receiving ADHD treatment or for those presenting with significant mental health risks. However, the variability in the quality and timeliness of documentation demonstrated that risk assessment and recording processes needed further embedding across the service.

At the previous inspection, we identified concerns about the safe management of opioid substitution treatment (OST). In response, the provider temporarily stopped accepting new referrals for patients requiring OST while it reviewed and strengthened its governance and clinical processes. The service developed a new OST protocol to support the safe assessment, treatment and monitoring of patients who may require this intervention in the future. Signposting to external services occurred for higher‑risk OST arrangements, which reduced the risk of unsafe OST provision. This followed best practice guidance. The protocol also set out the circumstances in which naloxone should be prescribed for people at risk of opioid overdose or opioid withdrawal, helping to ensure appropriate risk reduction measures are in place. This reduced the risk of avoidable harm and supported safer, more person-centred care.

The service had implemented arrangements to support safer physical health monitoring associated with medicines. Examples reviewed demonstrated clear shared care expectations for patients prescribed lithium, including regular blood test and ECG monitoring. In addition, the service had introduced a 6-lead ECG process, supported by a standard operating procedure, to help ensure timely assessment and appropriate referral for a full ECG when required.

The service operated a 24-hour crisis support line staffed by consultant psychiatrists on a rota basis. Patients could speak directly with an on-call clinician who provided advice, assessed risk and, where necessary, directed them to appropriate emergency services, including NHS crisis teams or AE. This helped ensure patients could access timely support during periods of crisis or deteriorating mental health.

Staff involved patients in care planning and risk management decisions. They adapted their communication to meet individual needs and encouraged people to provide feedback about their care and treatment.

At our inspection in October 2025, we identified concerns regarding environmental monitoring and the maintenance of clinical equipment. At this assessment, we found the provider had addressed these concerns and implemented effective systems to monitor environmental risks and maintain equipment.

Staff completed regular environmental audits, including health and safety and infection prevention and control checks. Managers carried out routine risk assessments of the premises.

Fire safety arrangements were well managed. Fire risk assessments were up to date, alarms were tested regularly and fire safety equipment was appropriately serviced.

The premises were clean, well maintained and equipped with safety measures including CCTV in communal areas and panic alarms in consultation rooms.

Although the service did not have a dedicated clinic room or store medicines on site, essential clinical equipment, including an automated external defibrillator, blood pressure monitors, weighing scales and an ECG machine, were regularly checked and maintained.

Since our assessment in October 2025, the provider had strengthened staffing oversight and support arrangements. Staff received appropriate supervision, training and development opportunities to support the delivery of safe care. Some policies detailing induction and supervision arrangements required updating.

The service employed a multidisciplinary workforce, including managers, administrators, 23 psychologists and therapists and 23 part time consultant psychiatrists working under practising privilege arrangements. This is where a medical practitioner is granted permission to work in a private clinic or independent private practice.

The manager maintained oversight of medical staffs’ records including professional registration, indemnity insurance and Disclosure and Barring Service (DBS) checks. We reviewed the records of 2 newly appointed consultants with practising privileges and found appropriate recruitment checks had been completed and documented before they commenced work.

Medical staff received external supervision and peer support. The service also provided informal reflective practice where required.

At the previous inspection, administrative staff did not receive formal supervision. At this assessment, formal supervision arrangements had been introduced. However, the supervision policy had not yet been updated to reflect these arrangements.

At the previous inspection, there was no clear process to ensure staff completed their induction within a defined timeframe. At this assessment, we found all new staff had completed an induction and records demonstrated this was completed promptly after they started work. However, the provider's induction policy had not been updated to specify expected completion timescales, which limited assurance that the process would be applied consistently.

Staff completed the mandatory training relevant to their roles, achieving an overall compliance rate of 85%. Training included safeguarding children and adults, medicines management, fire safety and information governance.

Since our assessment in October 2025, the provider had improved its management of infection prevention and control risks.

Staff maintained clinical equipment appropriately and kept records to demonstrate when equipment had been cleaned. Weekly infection prevention and control audits were completed to monitor compliance and identify any concerns.

Clinic areas were clean, well-furnished and well maintained. Cleaning schedules were up to date and demonstrated that environmental cleaning took place regularly.

Staff followed infection prevention and control practices, including hand hygiene procedures.

At our assessment in October 2025, we identified significant concerns regarding prescribing practices and medicines governance. At this assessment, we found the provider had strengthened oversight arrangements and met the requirements of the warning notice.

The provider had introduced an internal formulary and electronic system alerts to support safer prescribing. These systems highlighted non-formulary prescribing, duplicate prescriptions and other prescribing risks so they could be reviewed and acted on promptly.

The provider had strengthened controls over prescription stationery. Void and unused prescriptions were now monitored through regular reconciliation audits, with discrepancies investigated and escalated appropriately. It recorded prescriptions marked for voiding and the service completed weekly voiding and destruction logs with dual signatures.

Routine controlled drug and non-controlled drug prescribing audits were in place to identify unusual prescribing patterns, prescribing outside the formulary and medicines prescribed for longer than expected periods. Prescribers were required to provide a documented rationale where prescribing fell outside expected parameters.

Continuous audit processes, supported by the electronic prescribing system, enabled staff to identify and address medicines risks more quickly than at the previous inspection.

Information sharing arrangements had also strengthened, including a requirement for people to authorise communication with their GP before treatment was offered, which supported safer continuity of care and monitoring.

Staff followed good practice in medicines management and worked in line with national guidance. They also monitored the impact of medicines on patients' physical health, including where patients were prescribed high-dose antipsychotic medication.