ADHD Treatment Centre

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. This was the first assessment for ADHD Treatment Centre. This key question has been rated as good. This meant people were safe and protected from avoidable harm.

The service provided safe care and treatment. Systems were in place to identify, monitor and respond to risk. Staff reported incidents through an electronic system and discussed learning through governance processes and multidisciplinary meetings. Safeguarding systems were in place, and staff were trained to recognise and escalate concerns.

Clinical records and audit data showed risk assessments were completed and reviewed. Risk management included physical and mental health monitoring, clear escalation pathways, referral to external services and access to urgent psychiatric support where required. There were appropriate safeguarding systems and staff were trained to recognise and escalate concerns. Audit processes were in place, although not all audits consistently included formal action plans, named leads or re-audit dates.

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.

There were no significant incidents reported in the last 12 months.

Data reviewed for the period March 2025 to May 2026 recorded 4 incidents, including medication delays, side effects during titration and changes in peoples’ mental state while under shared care arrangements. Staff responded promptly by reviewing concerns, communicating openly with people and families, providing explanations, liaising with GPs, pharmacies and secondary mental health services, and taking appropriate action, including stopping medication, transferring care or making referrals where required.

All staff knew what incidents to report and how to report them. Staff described using an electronic incident management system to record incidents, with escalation to senior staff. Staff received feedback from incident investigations through governance processes and monthly multidisciplinary meetings. Learning was documented within the governance system, shared across the team and used to drive improvements.

Incidents were recorded, reviewed through governance and safeguarding processes, and learning was shared across the team to support continuous improvement. There was clear evidence that learning from incidents led to changes in practice, including strengthening prescribing and medicines governance processes, improving communication around prescriptions and staff leave arrangements, introducing structured mood and bipolar screening, enhancing titration documentation, formalising psychiatry referral pathways, increasing shared care reviews from 12 months to 6 months, and stopping medication where people did not attend required reviews.

Staff understood and applied the duty of candour, were open and transparent when incidents occurred, and used incidents as opportunities to improve safety and reduce the risk of recurrence.

Staff were debriefed following incidents and provided support through meetings, verbal communication and follow-up discussions to promote staff wellbeing and learning.

All people using the service were self-referred and privately funded, as there were no commissioning arrangements in place. This meant the service was not contracted or funded by the NHS, local authorities or other organisations to provide care on behalf of people using the service.

Referral and access processes required people to meet defined eligibility criteria, including the ability to engage in assessments, provide supporting information and allow access to relevant GP records. Staff told us referrals were reviewed before assessment and accepted where people’s needs could be met safely by the service. Where the service could not safely meet a person’s needs, staff signposted or referred them to psychology, therapy, psychiatry or crisis services.

Staff worked with GPs and other healthcare providers by sharing clinical information and treatment decisions to support coordinated care. Systems were in place to escalate concerns when risks increased, including discontinuing medication and transferring care to external mental health services where required.

The service had safeguarding systems in place and staff had completed safeguarding adults and children training appropriate to their roles. Training records showed 100% compliance with child safeguarding training and 92% compliance with adult safeguarding training. One newly appointed staff member had safeguarding training booked during May 2026 and was awaiting completion at the time of the assessment. Most staff had completed level 3 training, 1 staff member had completed level 4 training, and administrative staff had completed level 1 training where this was proportionate to their roles and responsibilities.

Staff understood how to recognise, and report concerns and described escalating safeguarding alerts to the safeguarding lead or senior manager in line with policy.

Staff could give examples of identifying and responding to safeguarding risks, including recognising signs such as changes in presentation, bruising and neglect. They described working with external agencies, including local safeguarding teams and healthcare services, to protect people. The safeguarding policy was reviewed annually and included clear procedures, guidance and relevant contact details. Staff across all roles understood their safeguarding responsibilities and knew how to access the policy.

The service mainly provided care through onsite appointments, with a smaller number of consultations delivered remotely. Staff described how they would respond to safeguarding concerns identified during onsite or remote contacts. This included promptly escalating concerns in line with safeguarding procedures and using emergency pathways where required. Staff told us they would take immediate action if they had concerns about a person's safety or wellbeing.

Staff described protecting people from harm by recognising deterioration in wellbeing and responding promptly when risks increased. Safeguarding processes included clear thresholds for referral and escalation, with staff required to report concerns to the safeguarding lead or a senior manager within 4 hours. There had been no safeguarding concerns identified and no safeguarding referrals made during the 6 months prior to the assessment. The registered manager, who was the safeguarding and Prevent lead, had overall responsibility for safeguarding oversight and governance. Safeguarding was a standing agenda item at multidisciplinary team and monthly governance meetings, providing ongoing oversight and opportunities for shared learning.

Mental Capacity Act

The service had processes in place to support consent and decision‑making as part of care delivery. All staff had completed Mental Capacity Act training in the last 6 months. Staff demonstrated a clear understanding of the Mental Capacity Act (MCA), including the 5 statutory principles, and were aware of and had access to the provider’s policy. Staff knew how to apply them in practice to support lawful, proportionate and person-cantered care. Staff knew how to seek advice within the service, including from the registered manager. Staff obtained and recorded consent during assessment and treatment, including medication reviews and information sharing with GPs.

We reviewed 4 people’s care and treatment records. These contained completed risk assessments and risk management plans. People and their families were informed about identified risks, supported to understand how to keep themselves safe and involved in care and treatment decisions. Risk management plans included advice on emergency contacts and support services, which was recorded in care records and shared through written information.

Risk assessments were embedded within initial assessments and reviewed throughout treatment and medication monitoring. Staff reviewed risks at every contact during medication titration, including monthly medication reviews, and at least every 6 months once people were receiving treatment under a shared care arrangement. Staff monitored risks such as deterioration in mental health, medication side effects, sleep disturbance and significant changes in mood or behaviour.

The service provided care in an environment that was safe, clean and fit for purpose. The service operated from premises within a GP practice and was required to comply with the service level agreement in place. Under this agreement, the GP practice was responsible for managing emergency arrangements, including responding to any fire incident. Staff were aware of local fire procedures, fire safety signage was displayed throughout the premises, and a designated fire marshal had been identified. The service also had access to emergency equipment provided by the GP practice. The consultation room we saw was clean, tidy and suitable for delivering care.

Staff completed an environmental risk assessment that was reviewed annually. The assessment covered fire safety, equipment, lone working, clinic safety and arrangements to support safe access and confidentiality. The operations manager was responsible for completing 6‑monthly reviews and maintaining oversight of any actions identified through the risk assessment process to ensure risks were monitored and addressed.

The service maintained a log of maintenance activities and safety checks, including fire systems, electrical equipment and medical devices. Most items were up to date; however, 1 item was overdue and there was no recorded action to demonstrate how this was being addressed.

Secure systems were in place to manage risks relating to medicines prescription and confidential records. Prescription pads and medication scripts were stored in locked cupboards and filing systems with restricted access. Office areas required key code entry, and only authorised staff could access records.

The service had enough suitably qualified staff to provide safe care and treatment and meet the needs of people. The workforce included a multidisciplinary team of clinical and administrative staff. Clinical staff included a non-medical prescriber, general practitioners, psychologists, a consultant psychiatrist and occupational therapists. Administrative staff provided patient experience and administrative support.

Over the last 6 months, the service workforce consisted of 11 staff members. This included 8 clinical staff, comprising 1 full-time registered manager and 7 self-employed clinicians, providing between 1.2 and 1.5 whole-time equivalent clinical capacity. The service also employed 3 administrative staff, providing 2.06 whole-time equivalent non-clinical support. Staffing requirements were determined by clinic activity and case mix, and staff were allocated accordingly.

The service did not use bank or agency staff but could access additional support through a GP under a service level agreement and through an agency if required. There were no vacancies at the time of assessment. Over the last 6 months, 1 staff member had left due to relocation and posts were filled promptly. There were no cancellations of care or appointments due to staffing shortages during the last 6 months. The service sickness absence rate over the last 12 months was 0.82%. The service told us sickness had no impact on the delivery of safe care.

Mandatory training compliance was 94% over the last 6 months. Training was tailored to staff roles and included the Mental Capacity Act, Deprivation of Liberty Safeguards, safeguarding adults and children, fire safety, information governance and equality and diversity. Outstanding training related to individual staff members and refresher training had been booked. Managers had introduced enhanced monitoring and automated alerts to ensure training remained in date.

The service monitored caseloads and staffing capacity using monthly reports and the clinical system. Between January and April 2026, the service delivered 658 clinical appointments, equating to approximately 493 clinician hours and an average requirement of 123 clinical hours per month. This information was used to inform workforce planning and maintain professional cover.

The service maintained a clean and safe environment and had systems in place to support infection prevention and control. An infection prevention and control policy was in place, which staff understood and followed. An infection control audit checklist was completed every 6 months by a designated manager and had been completed within the previous 6 months. The checklist directed staff to use the infection prevention and control policy as a guide and was used to monitor compliance and identify any actions required. Cleaning schedules, environmental checks and routine safety inspections were documented and monitored through the maintenance log and service level agreement arrangements.

All areas reviewed were clean, tidy and fit for purpose, including those used within the GP practice under the service level agreement. Staff followed infection prevention and control principles relevant to their roles, including appropriate hygiene practices during face-to-face appointments. Records demonstrated that equipment, facilities and safety checks were routinely completed and up to date.

The service followed good practice in medicines management and prescribed medicines in line with national guidance. Medicines were not stored or administered on site. Prescriptions were issued following a completed assessment, once a diagnosis had been established and the people had agreed to proceed with treatment. Staff discussed alternative options, including the risks and benefits of medication, to support informed decision-making. Prescriptions were then either collected from the GP practice reception or sent electronically to a pharmacy for dispensing and delivery.

Paper prescriptions we saw included people’s details, date of issue, prescribed medication, clinician signature and evidence of collection. Systems were in place to ensure security, including identification checks before prescriptions were released and restricted access to stored prescription pads. A tracking system was used to monitor prescriptions sent and received. This supported oversight of the prescribing process reduced the risk of prescriptions being lost or delayed and supported the safe and timely supply of medicines.

The service had policies and procedures to support safe prescribing, including a remote prescribing policy, medicines management and controlled drugs policies, and a standard operating procedure for prescribing. A medicines management lead oversaw practice, and managers completed audits to monitor compliance.

Staff reviewed the effects of medication on people’s physical health regularly. Monitoring included baseline physical health information, GP summaries, structured follow-up at 4-week intervals during titration and 6-monthly reviews once people were stable or in shared care. Where risks were identified, staff followed medicines escalation processes, including pausing or discontinuing medication, informing the person’s GP and referring to specialist services where required.