ADHD 360 Head Office

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At this assessment we have scored this rating as good. This meant people were safe and protected from avoidable harm.

The service had systems to identify, assess and respond to risks. Staff reported incidents electronically, and learning was shared through governance meetings and multidisciplinary discussions. Staff received safeguarding training and understood how to recognise and escalate concerns.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff at 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.

Staff responded promptly when incidents occurred. This included reviewing the presenting concerns, communicating openly with people and their families, and providing appropriate explanations and advice.

Staff understood their responsibilities for identifying, recording and escalating incidents. They described using the service’s electronic incident management system to document incidents and escalate concerns to senior staff. Incidents were reviewed through the service’s governance and safeguarding processes. Feedback and learning from investigations were shared with staff through monthly multidisciplinary meetings and other governance arrangements.

Learning was documented within the governance system and communicated across the service. We found evidence that the provider used learning to strengthen practice and reduce the likelihood of similar incidents recurring. Improvements included strengthening prescribing and medicines management, improving communication regarding prescriptions, clinical staff leave and stopping medication where people did not attend the clinical reviews required to support safe prescribing.

Staff demonstrated an understanding of the duty of candour and described being open and transparent with people and their families when things went wrong.

Staff were offered debriefing and support following incidents. This was provided through team meetings, verbal communication and follow-up discussions. These arrangements supported staff wellbeing, reflective practice and shared organisational learning.

Staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. This ensured continuity of care, including when people moved between different services.

The service had different referral and access arrangements for privately funded and NHS-funded patients. Privately funded patients self-referred to the service. People accessing the service through the NHS RTC pathway required a referral from their GP. At the time of our review of the provider’s published information, RTC referrals were accepted for children aged 8 years and over and adults aged 16 years and over.

The provider had established processes to assess whether it could meet people’s needs safely. Before an assessment was offered, referral and pre-assessment information was reviewed against defined eligibility criteria. People were required to engage with the assessment process, provide relevant supporting information and consent to the service accessing appropriate information from their GP records. This enabled staff to consider people ’s medical history, presenting needs and potential risks before deciding whether the service was suitable for them.

Referrals were accepted only where the person’s needs could be safely met within the scope of the service. Where the service was unable to meet a person’s needs, staff provided information about alternative sources of support or signposted and referred them to the appropriate services. These included psychology, psychiatry, secondary mental health and crisis services.

Systems were in place to support continuity and coordination throughout people’s care journey. Staff communicated the relevant clinical information, assessment outcomes and treatment decisions to GPs and other healthcare professionals involved in people’s care. Where appropriate, the service contacted people’s GPs to explore shared care arrangements once their treatment was stable and optimised.

Staff understood the risks associated with people receiving care from multiple providers or moving between services. Processes were in place to identify and escalate concerns when a person’s physical or mental health deteriorated, or their level of risk increased. Actions included completing a clinical review, communicating with the person and relevant healthcare professionals, stopping medication where clinically indicated, and referring or transferring care to external mental health or crisis services when the person’s needs could no longer be safely managed by the service.

These arrangements supported safe access to assessment and treatment across the service’s privately funded and NHS-funded pathways. They also promoted appropriate information sharing, coordinated decision-making and continuity of care when responsibility for treatment or prescribing moved between the service, GPs and other healthcare providers.

Evidence showed that the service worked effectively with individuals and healthcare partners to understand what safety meant to them and how best this could be achieved. The service maintained a strong focus on promoting people’s wellbeing while protecting their rights to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were identified and escalated promptly through the appropriate channels.

Staff had systems and processes in place to protect people from abuse, neglect and avoidable harm. The safeguarding policy was reviewed annually and provided staff with guidance on recognising and responding to different types of abuse, including reporting and escalation procedures and relevant contact details. Staff knew how to access the policy and understood the actions expected of them when safeguarding concerns were identified.

Staff had completed safeguarding adults and children training appropriate to their roles. Mandatory safeguarding training compliance was 96.8%, exceeding the provider's 95% target, with compliance rates of 95.1% for clinical staff and 98.5% for non-clinical staff.

Staff across different roles understood their safeguarding responsibilities and knew how to recognise, record and report concerns. They could identify potential indicators of abuse or neglect, including unexplained injuries, changes in a person's presentation or behaviour, deterioration in wellbeing and signs of neglect. Staff described assessing immediate risks, escalating concerns to the safeguarding lead or a senior manager and working with relevant external agencies where required.

The service delivered care mainly through remote online appointments and telephone calls, with face-to-face appointments available in hired locations, including GP surgeries. Staff understood how safeguarding risks could present across different settings and described monitoring changes in people's presentation and wellbeing throughout their care and treatment. Where risks increased, staff acted promptly, followed safeguarding pathways and used emergency procedures where there was an immediate risk to a person's safety or wellbeing.

Safeguarding was a standing agenda item at multidisciplinary team meetings and monthly governance meetings. This provided senior staff with opportunities to monitor safeguarding activity, review emerging risks and share learning across the service. Safeguarding activity was also overseen through a Patient Safety Safeguarding Assurance Framework, with audits of incidents, referrals and safeguarding advice used to support ongoing learning and improvement.

Data reviewed for June, July and August 2026 showed 18 external safeguarding referrals/incidents. Of these, 14 (77.8%) had concluded and 4 (22.2%) remained open and continued to be monitored. Records evidenced escalation to the appropriate external agencies, including local authority adult and children's safeguarding teams, multi-agency safeguarding hubs (MASH), multi-agency risk assessment conferences (MARAC), mental health and crisis services, and housing services.

Where safeguarding concerns also involved patient safety, these were considered through the service's patient safety incident response framework (PSIRF) alongside the appropriate safeguarding pathway. During June, July and August 2026, the provider completed 11 patient safety incident investigations, comprising 4 on June 3 in July and 4 in August, with a further incident subject to follow-up review. Incidents were reviewed through local incident-management processes, with actions implemented and concerns escalated where required. The weekly patient safety triage meeting determined whether incidents required a formal learning response, and the provider monitored investigation outcomes and identified learning.

Mental Capacity Act

ADHD360 had processes to support consent and shared decision-making throughout assessment and treatment. People were offered personalised, patient-led treatment plans and were supported to make informed choices about their care.

Staff obtained and recorded consent for assessments, treatment, medication reviews and the sharing of relevant information with GPs and other healthcare professionals. Staff understood the principles of the Mental Capacity Act and knew how to access the provider’s policy and seek advice from clinical leaders where a person’s capacity to make a specific decision was in doubt.

Staff considered capacity in relation to the individual decision and supported people to understand, retain, use and communicate relevant information. Where appropriate, staff adapted communication and involved representatives in accordance with the person’s wishes and lawful consent arrangements.

We reviewed 6 people’s care and treatment records. Each record contained a risk assessment and risk management information. The risk assessments did not consistently identify or clearly summarise all known individual peoples risks and concerns. However, we did find that staff had reported peoples risks fully in people’s assessment forms, consultation notes, medication reviews and monitoring documentation. As staff had not transferred these risks on to persons formal risk assessment, managers of the service could not be assured that staff were taking actions to reduce the risks for people using the service. The quality and level of detail within risk assessments varied between records. This increased the risk that staff reviewing a person’s care might not have immediate access to a complete and up-to-date overview of their risks and associated management arrangements.

Despite these inconsistencies, people and, where appropriate, their families or representatives were provided with information about identified risks and involved in decisions about care and treatment. Staff supported people to understand the potential risks associated with their treatment, recognise signs of deterioration and know what action to take if any concerns arose.

Risk management information included advice about emergency contacts and available support services. This information was documented within people’s records and shared through written and online information. However, it was not always brought together within a consistent and clearly documented risk management plan.

Risk screening formed part of ADHD360’s assessment pathway, and included questions about people’s mood, health and daily functioning. Following diagnosis, clinicians developed personalised treatment plans and monitored people regularly while identifying an appropriate course of treatment.

During medicines titration and ongoing reviews, clinicians considered changes in mental health, medication side effects, sleep, mood, behaviour and physical health. Where concerns were identified, staff took proportionate action. This included increasing monitoring, reviewing, adjusting, pausing or stopping medication, providing safety advice, liaising with the person’s GP, or referring them to mental health, specialist or emergency services. Once treatment was stable and optimised, people could move to shared-care arrangements, with the provider retaining responsibility for specialist oversight and treatment reviews.

Evidence demonstrated that the service had effective systems in place to identify, monitor and control environmental risks, ensuring that equipment, facilities and technology supported the delivery of safe, high‑quality care. Leaders and staff showed a clear understanding of their responsibilities in maintaining safe environments across all hubs.

The provider operated within 5 hubs in Lincoln, which were used as office accommodation for staff. No people using the service were seen at the hubs we visited, and care and treatment were not delivered from these locations.

People predominantly accessed the service remotely through telephone calls, online video consultations and written correspondence. Systems were in place to support staff to deliver care remotely and to maintain the security and confidentiality of people’s personal and clinical information. Access to office areas and confidential records was restricted to authorised staff.

Where a person requested or required a face-to-face appointment, the provider hired consultation rooms within local community venues, such as GP practices. Responsibility for the general safety and maintenance of these premises was shared with the organisation providing the venue and was set out within the relevant hire or service-level arrangements.

The provider was responsible for assuring itself that any externally hired room was safe, suitable and appropriate before it was used. This included considering privacy and confidentiality, accessibility, fire and emergency arrangements, lone working, infection prevention and control, and access to suitable equipment. Staff were expected to familiarise themselves with the local safety and emergency procedures at each venue.

As no people received care at the Lincoln hubs, we did not inspect an environment used for face-to-face consultations. We were therefore unable to directly observe whether the rooms hired by the provider consistently supported the safe delivery of care. The provider needed to maintain effective oversight of all external venues and retain evidence that appropriate safety and suitability checks had been completed before people were seen there.

Environmental risk assessments were completed for the Lincoln staff offices and reviewed annually. These considered risks relating to fire safety, electrical equipment, lone working, office security and the storage of confidential information. The provider maintained a log of maintenance activities and safety checks for the staff hubs, including fire systems and electrical equipment.

Secure arrangements were in place to protect prescription stationery and confidential records held at the hubs. Prescription pads and medication scripts were stored in secure cupboards with restricted access. Office areas required key-code entry, and only authorised staff could access people’s records.

The service had effective systems to ensure it maintained sufficient numbers of suitably qualified, skilled and experienced staff to meet people's needs safely. Workforce planning was based on referral volumes, pathway demand, clinical complexity and available capacity rather than fixed staffing levels. The multidisciplinary workforce included nurses, pharmacists, independent prescribers, clinical leaders, and operational and administrative staff. Leaders monitored workforce capacity through a red, amber and green escalation system, and a clinical duty team provided cover for staff absence, reallocated assessments, prioritised work according to clinical risk and escalated pressures when required.

Staff received appropriate training, supervision and development to support safe and effective care. Mandatory training compliance exceeded the provider's target of 95%, with compliance rates of 95.1% for clinical staff, 98.5% for non-clinical staff and 96.8% overall. Although Oliver McGowan Tier 2 training compliance was lower at 27.3%, leaders had implemented a plan to achieve between 91.8% and 95% compliance by March 2027.

The provider had systems to monitor staff competence and support continuous professional development. New clinicians completed a structured, CPD-accredited training programme through the ADHD360 Academy, covering ADHD assessment, diagnosis, treatment, medicines management, risk assessment and supervised clinical practice. Clinicians were required to demonstrate competency through supervised patient assessments against a structured framework that assessed areas including communication, diagnostic decision-making, medicines management, consultation skills, risk management, professional conduct and problem-solving. The framework also considered learning from any areas of concern and supported the sharing of learning across teams.

Leaders monitored supervision and appraisal compliance to ensure staff received appropriate support. Clinical supervision compliance improved from 82% between April and June 2026 to 90% in August 2026, although compliance varied across teams between 78% and 100%. Managers tracked outstanding supervision and implemented targeted actions where staff had not received supervision within the required six-month period. Appraisal compliance was 79% under the previous six-monthly framework and 98% against the revised annual standard introduced in August 2026. The new performance framework required all staff to receive an annual appraisal alongside at least five one-to-one meetings each year to review wellbeing, caseload management, performance, training and professional development.

Ongoing learning was supported through a programme of clinical training delivered throughout 2026. Training topics included differential diagnosis, screening tools, risk management, physical health monitoring, medicines management, safeguarding, consent, patient voice and collaborative safety planning. The provider also used themes identified through audits and medicines incidents to inform training, helping staff learn from trends, incidents and opportunities for improvement

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.

Staff assessed and managed infection prevention and control risks across their service. However, the Lincoln hubs we visited were used solely as staff offices. People did not attend these premises for assessment, care or treatment.

The staff offices we visited were of a high standard, clean and tidy. Cleaning arrangements and routine environmental checks were documented and monitored. These arrangements supported a clean and safe working environment for staff.

Where people requested or required a face-to-face appointment, the provider hired consultation rooms in local premises, such as GP practices. The provider did not routinely see people within its own Lincoln hubs. Staff were expected to follow the infection prevention and control procedures applicable to the hired venue and apply appropriate hygiene practices during face-to-face appointments.

Responsibility for cleaning, environmental maintenance and some infection prevention and control arrangements at hired premises rested with the staff member using the room at the time and the organisation managing the venue. The provider remained responsible for assuring itself that hired rooms were clean, suitable and safe before they were used for face-to-face appointments.

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.

The service supported approximately 27,000 people who received prescribed medication. Systems supported assessment, prescribing, supply, monitoring and review of medicines. Medication was prescribed following assessment, confirmation of diagnosis and a clinical decision that treatment was appropriate. Clinicians discussed treatment options, benefits, risks and potential side effects, and involved people in decisions about starting or changing medication.

Treatment included titration to identify an appropriate medicine and dose, followed by ongoing reviews. Staff monitored effectiveness, tolerances, side effects, physical health measurements, sleep, mood and changes in mental wellbeing or behaviour. Where concerns were identified, clinicians increased monitoring, adjusted, paused or discontinued treatment, communicated with the person’s GP, or referred to specialist or emergency services. Once treatment was stable and optimised, the provider could seek a shared-care arrangement with the person’s GP while retaining specialist oversight and review responsibilities.

Prescriptions were generated, printed and authorised by appropriately qualified clinicians before being transferred securely to the provider’s dispensing pharmacy. People did not routinely handle physical prescriptions. The provider-maintained prescription histories and audit trails and monitored prescribing volumes, dispensing information and emerging trends. Policies included medicines management, controlled drugs and remote-prescribing arrangements, supported by oversight from a medicines management lead and clinical audit processes.

The provider did not store or administer medicines at its Lincoln premises. These were staff offices and people did not attend them for care. The dispensing pharmacy supplied medicines, including controlled drugs, directly to people, reducing risks associated with on-site storage, stock control and unauthorised access.

The provider closely monitored medicines safety through incident reporting and review processes. Between June and August 2026, 67,901 prescriptions were issued, with 96 medicines-related incidents recorded (0.14% of prescriptions). Most incidents related to duplicate prescribing, lost prescriptions and prescribing errors. The low incident rate and oversight processes supported the safe management and optimisation of medicines.

Potential consequences included delayed or interrupted treatment, duplicate supplies, unintended dosing and medicines being delivered to an incorrect address.

Incidents were reviewed through clinical supervision, audit, medicines-management meetings and governance forums. Learning was shared through monthly medication-error reports, team reflection logs, staff guidance and updates to the online knowledge bank. Actions included strengthening shared-care checks, introducing prompt notifications to GP practices following treatment changes, reinforcing prescription-tracking requirements and updating the prescription-posting policy. A multidisciplinary shared care working group was established to oversee further improvements.

Further controls to manage temporary delivery addresses were planned with a new pharmacy partner from November 2026 and were not yet operational at the time of the review.