Transforming Mind Solutions

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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

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 requires improvement.

The service was in breach of legal regulation in relation to medicines management (Regulation 12.)

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.

The service did not always have a proactive and positive culture of safety, based on openness and honesty. They did listen to concerns about safety and investigated and reported events, however, lessons were not always shared with staff to continually identify and embed good practice.

The provider had an incident management policy and procedure in place that provided guidance for staff in managing, investigating and learning from incidents. However, the policy lacked detail on how incidents should be reported. The policy stated, “incidents must be reported as soon as reasonably practicable using the service’s incident reporting process,” but further guidance on this process was not documented within the policy. The service had a duty of candour policy which detailed action to be taken following identification of an incident resulting in moderate/severe harm, or death.

The provider had an incident and near miss register in place which detailed the incident category, incident description, immediate actions taken, severity rating and learning identified. There were 9 incidents between July 2025 and January 2026, mostly relating to non-clinical/operational and equipment/technology. Staff had identified 1 clinical incident, relating to a delivery of controlled drugs being inappropriately left by the courier. Although it was identified on the register what action had been taken and any identified learning, we did not see evidence this incident was discussed in meetings. Learning from incidents was not a standard agenda in clinical governance and team meetings.

Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and safety was a top priority.

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.

There were systems in place for processing information relating to new patients. The service worked with other providers to share information for when patients moved between services. Referrals and test results were managed in a timely way.

Information was shared with the patients’ NHS general practitioner (GP) where the patient had provided consent. Where consent was not given, the service reviewed the information and ensured any significant or relevant health information was communicated appropriately to the patient. Leaders told us patients were made aware of the risks associated with not coordinating with their GP, including potential lack of continuity of care. However, we found staff had not always ensured they consulted with patients’ GP’s prior to commencing treatment, including prescribing of controlled drugs. We had concerns the provider did not have access to adequate information to enable them to prescribe medicines safely.

There was an exclusion and referral pathways policy in place that defined the exclusion criteria applied during the assessment of new referrals. The service undertook a suitability screening and clinical assessment prior to commencing treatment. For example, those with Attention Deficit Hyperactivity Disorder (ADHD) did not fall inside the scope of treatment offered. Those who were excluded from treatment were appropriately signposted or referred to their GP and/or specialist NHS or private services.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They did not always concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider had policies for safeguarding both children and adults in place at the time of the assessment. The policy outlined the role of the Designated Safeguarding Lead. However, we found the policy did not provide clear guidance for staff in relation to safeguarding training level and frequency of refresher training.

The safeguarding policy detailed the procedure for staff to follow upon identification of a safeguarding concern, which included a referral to external agencies. We requested information on any external safeguarding referrals made within the 6 months preceding the assessment. We were informed no referrals were made as thresholds had not been met.

Staff were not always trained in safeguarding procedures. Despite the policy stating all staff must complete safeguarding training as part of the induction, we saw in training records 2 administrative staff members and 1 practitioner had not completed any level of safeguarding training. Therefore, we could not be assured staff were trained to identify when patients may be at risk of or experiencing abuse or neglect. This was raised with the provider, and leaders informed us they had a completion deadline of 14 days from 22 February 2026 for all staff to receive safeguarding training relative to their role.

Safeguarding arrangements were kept under review through governance processes. The service held monthly clinical governance meetings where safeguarding was discussed. For example, in December 2025 the safeguarding log was reviewed, and it was discussed in the meeting there were no open safeguarding concerns. However, we did not see evidence safeguarding was a standard agenda item in clinical governance and team meetings.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We saw evidence in care records of holistic treatment plans and risk assessments. Clinical staff completed an initial assessment where medical history and ongoing treatment aims were discussed. Clinical staff considered this when creating person-centred treatment plans. Staff involved patients in the completion of their treatment plans and sought informed consent to proceed with the recommended treatment. We saw evidence concerns were escalated appropriately, and patients were informed where to escalate any concerns, including physical health deterioration.

Patients and carers we spoke with were positive and told us they felt involved in care decisions and treatment choice. One patient told us, “Care is explained in detail and the side effects. Been a couple of times and every time the process is re-explained to you.”

There were regular multidisciplinary meetings where staff discussed patient risks. We reviewed meeting minutes and found new patients and patients currently receiving treatment were discussed, including clinical suitability and any identified risk factors.

Although we observed good practice in relation to TMS treatment, we did have concerns in relation to the documentation of consent of those under the age of 16 (Gillick competence) and staff not obtaining GP records prior to treatment with controlled drugs. These concerns are discussed in the medicines optimisation quality statement and effective key question.

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

The service had an environmental risk assessment in place where risks had been identified and addressed. The risk assessment detailed the risk identified, who may be harmed, control measures in place and the risk rating. The risk assessment detailed service-specific risk considerations such as electrical safety controls for the clinical equipment.

Staff undertook health and safety audits of the environment. The audit checked for compliance with general workplace safety. For example, adequate lighting, fire safety, electrical safety, equipment and machinery, hazardous substances and emergency procedures. We reviewed the most recent health and safety audit which took place in November 2025. Portable appliance testing was completed on 26 November 2025.

The premises was equipped with a first aid box that was easily accessible. We reviewed a first aid box audit from October 2025 which checked the quantity and expiration dates of each item. This audit did not identify any actions for staff.

The provider had a business continuity plan in place that was monitored and reviewed. The policy provided guidance for staff to maintain continuity in the event of disruption.

The service did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff training compliance levels were low for administrative staff. Leaders told us mandatory training included safeguarding, infection prevention and control, Mental Capacity Act and consent, information governance and health and safety. We reviewed staff training records and found administrative staff had not completed their mandatory training, which meant overall compliance rate across all staff members was 63%. This was raised with leaders as part of our assessment and we were informed an action plan was put in place to manage compliance rates of training, however we received limited assurance on how this would be achieved. This is discussed in more detail in the Governance, Management and Sustainability section of this report.

The service consisted of a small team including an operations director, operations manager, medical director, lead practitioner and clinic coordinator/administrator. We discussed roles and responsibilities with leaders and found the size of the team was enough to meet the needs of the patient group and avoid delay in care and treatment.

We reviewed staff retention data for 4 months preceding our assessment. We found 3 staff members had left, including 2 staff members in management positions. Leaders told us there were no staffing shortages or disruption to patient care as a result of these changes and we saw 1 role had been promptly filled. In the 4 weeks preceding our assessment, leaders had implemented an organisational restructure to account for gaps in management positions. We saw evidence this had been managed proactively and had no impact on patient care.

We observed the team working well together and we reviewed meeting minutes of regular clinical governance and multidisciplinary discussions. Administrative staff did not attend clinical governance and multidisciplinary meetings. Team meetings including administrative staff were less regular. Leaders told us the team had daily huddles and would have discussions informally throughout the day. These meetings were not documented, so we could not review meeting minutes to evidence staff attendance, agenda items or frequency of these meetings.

Staff were receiving regular supervision and annual appraisals which provided opportunities to reflect on and learn from any areas of improvement and discuss areas for personal support and professional development.

The provider had systems in place for safe recruitment of staff. This included proof of identify, right to work checks, Disclosure and Barring Service checks and verification of professional qualifications and registration.

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.

The service had an Infection Control policy in place. This included information on the procedures for staff to follow in relation to hand hygiene, personal protective equipment (PPE), environmental cleaning, clinical equipment, waste management, management of spillages and exposure, staff health and outbreak management. The policy included a risk assessment which documented potential risks and control measures in place. For example, poor hand hygiene was identified as a risk and control measures included hand hygiene training for staff and accessible sanitising stations.

Staff undertook quarterly infection prevention and control (IPC) audits to review compliance with the management of infection risks. We reviewed the audit for November 2025 and found most areas were compliant and for those areas that were partially compliant, actions had been documented.

The environment was noted to be clean and tidy during our onsite visit with accessible hand-washing facilities for staff. Feedback from patients we spoke with was positive in relation to the cleanliness of the environment.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Clinical staff discussed medical history with patients to determine risks of potential drug interactions. Following assessment, staff would approach patients’ GPs to request they prescribe and continue with ongoing monitoring of agreed medicines. Staff had sought consent to contact patients’ GPs and recorded this in care records. Staff ensured patients were aware of all recommended medicines reviews and monitoring.

Although most prescribed medicines were managed through the patient’s GP, staff did prescribe medicines within the service. We found staff had not always consulted with the patient’s GP to seek medical records prior to prescribing the controlled drugs, oral ketamine solution and nasal esketamine. Three patients were prescribed oral ketamine solution in the 12 months preceding our assessment. Leaders told us they did not have a process in place to review patient’s medical records prior to the prescribing of ketamine and esketamine and would rely on consultations with the patient to discuss medical history and potential drug interactions. This process was not in line with General Medical Council (GMC) guidance which states prescribers must have access to relevant information from the patient’s medical records before prescribing controlled drugs and other medicines where additional safeguards are needed, unless is it being done to avoid serious harm. Therefore, we were not assured prescribing staff had accurate information to make safe clinical decisions.

We found staff had not always received training to safely support with the self-administration of ketamine. We saw in clinical notes 1 staff member had completed the post dose monitoring following the self-administration of oral ketamine solution. However, we found in training records this staff member had not completed first aid or basic life support training. We were therefore not assured staff could safely intervene in the event of physical health concerns.

Medicines were rarely stored onsite however we found there were appropriate facilities to store this securely. Staff regularly checked the stock levels and expiry dates for all medicines. However, we were not assured the provider had appropriate protocols in place to appropriately denature (the process of rendering unused, expired or unwanted medicines as unfit for use, unrecoverable and unrecognisable) controlled drugs stored onsite. Leaders did not provide clear evidence in relation to their medicine disposal procedures. The provider had a medicines management policy in place however this lacked detail in relation to the safe disposal of medicines.

We recommended for the provider to review these processes to ensure they are in line with regulations.

Leaders told us they had access to colleagues within other services for peer review of clinical decisions. However, staff did not carry out regular and effective internal pharmacy audits to identify areas for improvement. The lack of internal pharmacy audits limited overall oversight of medicines management.

Staff helped people understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.