The London Neuropsychiatry Clinic

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

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

The service was in breach of legal regulation in relation to Regulation 18: Staffing and Regulation 17 - Good Governance.

Some aspects of the service were not always safe. We found that administration staff had not been given additional formal training in safeguarding, which would have benefited them in their patient facing role.

The service did not carry out patient records and prescribing audits to ensure safe prescribing was taking place.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. They had policies and procedures in place to promote listening to concerns about safety and learning lessons to continually identify and embed good practice.

People receiving care told us they felt supported to raise concerns and that staff treated them with compassion and understanding. The Neuropsychiatrist also attended Multidisciplinary Team (MDT) meetings with other cannabis prescribers and presented case studies to support continuous learning and uphold high standards of patient care.

The provider had established policies and procedures for staff to report incidents, near misses, and safety events. However, there was no incident log in place to record such occurrences. Staff reported that since registration, there had been no complaints or incidents, and as a result, there was no documented evidence of investigations, or any changes made as a result of learning from incidents. Despite this, the provider offered assurance that robust systems were in place to effectively review and respond to any complaints or incidents should they arise.

The referral processes to the service ensured that essential information about the patient was received to determine if the patient’s needs could safely be met by the service. On discharge from the service a detailed discharge letter is sent to the referrer.

Care records detailed multidisciplinary input in the care and treatment of individual patients. The provider conducted safety risk assessments for patients, staff and the environment. There were appropriate safety policies in place which included safeguarding policies and an infection and control policy. However, these were out of date.

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.

We found a combination of good practice and areas requiring improvement in the service’s approach to safeguarding and safety.

There were concerns regarding the absence of safeguarding referrals to the local authority. Although staff generally responded promptly when concerns were identified, there were instances where these concerns were not shared as effectively as expected. This raises questions about the consistency of the service’s safeguarding escalation processes and its ability to ensure timely multi-agency intervention.

Administrative staff played a key role in patient triage and maintained regular contact with individuals, particularly during periods of deteriorating mental health. Despite their frontline involvement, they had not received safeguarding training. The current escalation protocol relied on these staff members to identify and pass concerns to the Psychiatrist, who also served as the Registered Manager. This reliance on untrained staff may pose a risk to timely and appropriate safeguarding action.

The safeguarding policies were out of date, and there was no clear definition when safeguarding concerns met the threshold for a safeguarding referral to be made to the local authority.

The service maintained a list of individuals identified as vulnerable, helping to ensure that those at higher risk were monitored and supported appropriately.

In contrast, clinical staff had received up-to-date safeguarding and safety training appropriate to their roles and demonstrated a clear understanding of how to identify concerns. The service worked collaboratively with individuals to understand what safety meant to them and partnered with other organisations to promote safe practices. Staff supported people’s right to live safely and free from avoidable harm and generally acted promptly when concerns were raised.

There were systems to assess, monitor and manage risks to patient safety.

Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. The service had a medical emergencies policy for both face-to-face clinics and online appointments, which detailed the appropriate procedures for staff to follow.

Staff assessed patient risk during appointments and recorded this in clinic letters sent to the GP. If a patient’s needs could not be safely met by this service, staff discussed other more appropriate options with the referrer, for example a community mental health team or inpatient support. Staff assessed risk at each appointment as a patient’s mental health could deteriorate. If a patient needed support outside of clinic hours they were encouraged to speak with their GP or emergency services, depending on the severity of the concern.

There were appropriate indemnity arrangements in place for the service.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Fire Risk assessments were in place, and fire drills did occur. Staff involved the necessary healthcare and social care services to support patients, where necessary.

Appropriate external contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

The provider carried out staff checks at the time of recruitment. Disclosure and Barring Service (DBS) checks were undertaken where required. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

Staff training had been provided by accredited external providers, such as the Royal Society of Medicine, and the Neuropsychiatrist had completed all mandatory training.

However, the Service Level Agreement SLA Cross-cover agreement for unforeseen circumstances and holiday arrangements with another psychiatrist was out of date.

The Neuropsychiatrist participated in peer support supervision and appraisal. However, administrative staff did not receive regular supervision. Supervision for staff is crucial to ensure safe, effective and compassionate care delivery.

The building was visibly clean, had good furnishings and weas well maintained. 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. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

We found some areas of medicines management that could be improved.

The service had systems in place for prescribing medicines, including controlled drugs (medicines with the highest level of control due to their risk of misuse and dependence, CDs), which minimised risks to patients. Prescription stationery was stored securely, and its use was monitored.

The service prescribed cannabis-based products for medicinal use (CBPMs), which are controlled drugs. Although the service did not have documented eligibility criteria for accepting patients seeking treatment with medical cannabis, the clinician had access to relevant patient histories, including information from patients’ GPs and other healthcare professionals. Prescribing decisions were discussed with an external specialist doctor before treatment was initiated, in line with legislation. However, we found it was not always clearly documented whether the choice of preparation, dosage and follow-up arrangements had been discussed and agreed.

Patients were actively involved in reviews of their medicines. The clinician helped patients understand how to use their medicines safely, and patients knew what to do if their condition did not improve or if they experienced unexpected side effects.

The provider had effective systems in place to identify, manage and act upon patient safety alerts and medicine recalls. However, the service did not carry out regular audits of patient records and prescribing practice to provide assurance that prescribing was consistently safe and effective.