Transforming Mind Solutions

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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 good governance (Regulation 17.)

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Leaders did not ensure there was a clearly documented strategy in place to provide guidance for staff on the vision, values and purpose of the service. Leaders told us they had a mission statement staff could provide input on via team meetings. We reviewed staff meeting minutes and did not see evidence that the mission statement or strategy were discussed. We were therefore not assured staff had opportunities to contribute to discussions about the provider strategy or their role in achieving it.

Staff we spoke with could provide examples on the provider’s commitment to providing a responsive service to patients. Staff spoke positively about the friendly and supportive team culture.

Leaders did not always understand the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively or they did not always do so with integrity, openness and honesty.

The service was led by a senior management team which included an operations director who was also the registered manager and a medical director who was also the nominated individual. Although the leaders had the qualifications to perform their roles, they did not always demonstrate an effective oversight of the service they managed. During our inspection we found shortfalls related to the quality and safety of the service which leaders had overlooked. This included gaps in medicines management, staff training and consent. These are discussed in more detail in other sections of this report.

Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked well with each other.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Patients and carers we spoke to told us they would feel confident to speak up if they had concerns, however most added they had never needed to.

Staff were aware of how to raise concerns and told us they were confident they would be listened to. The team was very small so there was not an established Freedom to Speak up arrangement in place, however leaders could provide examples of staff feedback and how that had led to change within the service.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. The provider had an equal opportunities and anti-discrimination policy that provided guidance for staff on promoting equality, diversity and inclusion within the workplace. However, the policy stated, “All staff must complete mandatory Equality, Diversity and Inclusion training upon induction and refresher training annually,” but we did not see evidence all staff were trained in line with provider policy.

The provider made reasonable adjustments where necessary to support staff, including flexible working arrangements.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders did not demonstrate a clear oversight of the service they managed. Our inspection highlighted shortfalls in several areas including medicines management, staff training, consent and policies and procedures. Leaders had failed to identify those gaps as governance structures were not appropriately monitoring and improving the service.

The provider had a risk register in place which detailed a range of risks specific to the service and mitigations for these, however, it did not reflect the risks highlighted during this inspection.

The provider had not ensured an appropriate range of policies and procedures were available for staff to refer to. For example, the provider did not have policies on all treatments offered, patient risk assessments or physical health monitoring. We reviewed a physical health monitoring and management statement. Leaders told us this was “policy-equivalent,” however, we were not assured this was in place prior to our assessment and available to staff. These documents, and the policies and procedures the provider had in place lacked detail and did not provide clear guidance to staff. For example, the provider had a Controlled Drugs (Ketamine) Handling and Dispensing standard operating procedure in place, however, this lacked detail on the disposal and destruction of controlled drugs. The policy stated, “expired or unusable stock is destroyed in accordance with controlled drugs regulations,” but further guidance on these regulations were not provided. Therefore, we were not assured staff had clear guidance on the disposal of controlled drugs.

Leaders did not always have effective oversight of physical health monitoring procedures. They told us patients who had received oral ketamine solution must be monitored for at least 90 minutes. Although we saw evidence of staff completing post dose monitoring in clinical records, this was not completed in line with what leaders had told us. We also did not see evidence this procedure was documented in the provider’s policies and procedures so were not assured staff had clear guidance to follow in relation to this.

The provider did not provide evidence of clear oversight of mandatory training and the frequency of refresher training. Several policies referenced training staff had not received or lacked detail on the level staff should be trained to. For example, the provider’s medicines management policy did not provide guidance on the training staff should receive to safely support with the administration of ketamine and esketamine, nor the frequency of refresher training. We also found the safeguarding policy provided guidance on the frequency of refresher training but did not provide information on the level of training each staff member must complete.

The provider had developed an action plan following identification of staff training concerns. The action plan provided information on actions implemented and mitigations in place whilst staff were completing mandatory training, such as “No staff member may deliver care or act as a formal chaperone until mandatory training is completed.” However, the action plan did not provide specific deadlines or assigned responsibilities for each identified action, we were therefore not assured this would be effectively implemented.

The provider had not always ensured consent was documented within care records which did not reflect the current national guidance. We did not see evidence of documentation of Gillick competence for patients aged under 18 or consent to the administration of unlicensed ketamine treatment. Although leaders told us consent was taken verbally, poor record keeping meant we could not be assured informed consent had taken place for all treatments.

The provider held monthly clinical governance meetings. We found this meeting did not follow a standard agenda and did not always include key topics such as safeguarding or lessons learnt from incidents. Although there had been few incidents in the months preceding our assessment, we did not always see evidence incidents that had occurred were discussed during this meeting. Therefore, we were not assured lessons learnt were shared with staff to prevent incidents from reoccurring.

Leaders did not understand the arrangements required for working with external teams to ensure continuity of patient care and treatment. The provider had no system in place to ensure they could access and review GP records before prescribing controlled drugs, increasing the risk of harm to patients. However, we did see evidence of regular multidisciplinary team meetings for staff delivering treatment to attend.

Some governance processes worked more effectively, including oversight of IPC and health and safety risks within the environment. The service had a plan for emergencies to ensure business activities could continue. The provider was also proactive in addressing some of the concerns we identified, for example, documentation around informed consent was amended during our assessment. Further work was required to ensure these improvements were embedded into practice.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The provider shared information and learning with partners and collaborated for improvement. Leaders told us they had developed guidance to support training across other TMS providers.

Staff involved the necessary health and social care services to ensure continuity of care. We saw evidence of the service communicating with the patient’s GP in relation to ongoing monitoring of prescribed medicines.

Leaders told us they worked collaboratively with the NHS and integrated care board to discuss the TMS provision.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff engaged with national and international research and professional forums. We saw evidence leaders had attended the Royal College of Psychiatrists International Congress and displayed posters to present findings from clinical work.

Leaders told us they had begun work on monitoring patient outcomes to contribute to effective practice and research. They told us they were developing a new system to monitor treatment outcomes with the aim to improve patient care and support future research and publications. This is further discussed in the effective section of this report.

The service had a standard operating procedure (SOP) in place to define the development, management and monitoring of a quality improvement plan. Leaders told us they measured the effectiveness of treatments and used this to improve patient outcomes; however, we did not see evidence of any documented quality improvement objectives around this.