The Psychiatric Care 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 rated safe as Good because:

Staff had a good understanding of incident reporting, safeguarding adults, and the Duty of Candour.

Patients were actively involved in risk assessment and risk management planning.

The premises were clean, safe, and well maintained, with effective infection prevention and control arrangements.

Recruitment processes were robust, with appropriate pre-employment checks completed for staff.

Medicines were generally managed in line with national guidance, with clear monitoring of treatment effectiveness and side effects.

The service was in breach of legal regulation in relation to seeking confirmation from a person’s GP about current medications before prescribing, specifically for self-referring clients.

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.

The service had a positive culture of learning, based on openness and honesty. They reported incidents, listened to concerns and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood their responsibilities to raise concerns and report incidents and near misses. Incidents and safety alerts were a standing agenda item at governance meetings, enabling the service to review and discuss any safety concerns.

The service acted on and learned from external safety events, including patient safety and medicines safety alerts. The provider received medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) and kept up to date with relevant clinical guidance published by the National Institute for Health and Care Excellence (NICE).

The provider was aware of and complied with the requirements of the Duty of Candour. A Duty of Candour policy was in place, and the provider promoted a culture of openness and honesty. Feedback from patients indicated that staff were open and honest in their interactions.

The referral process, inclusion and exclusion criteria were clear to those accessing the service and to staff.

Where the service was unable to meet a patient's needs safely, staff signposted individuals to appropriate alternative services.

Service leaders met regularly to discuss complex cases, incidents and complaints. These meetings provided oversight of service delivery and supported learning and improvement.

Staff worked collaboratively with relevant health and social care services to support continuity of care during treatment and following discharge. This included partnership working with GPs, therapists and community mental health teams to facilitate timely information sharing and coordinated care.

The service made clear, through written information provided to patients, that it did not offer emergency or crisis support. Patients were given guidance on how to access emergency mental health services if required.

The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. For example, consent was obtained to share Doctors primarily relied on information provided by patients regarding their current medication and did not consistently seek confirmation from the person's General Practitioner (GP). Staff must ensure medication reviews form part of patients' ongoing care and treatment pathways and are completed consistently in line with Regulation 12(2)(b). assessment letters with the GP.

Staff had completed safeguarding adults’ level 1, 2 and 3 training and knew how to recognise and report safeguarding concerns. Compliance with safeguarding adults training was 100%. At the time of inspection, the staff had not completed training in safeguarding children, but they were enrolled into this, and we saw records to show level 1 and 3 training was completed soon after the inspection took place.

Staff demonstrated an understanding of how to identify adults at risk of, or experiencing, abuse and neglect and knew how to respond appropriately. They understood their responsibilities to raise safeguarding concerns and worked with partner agencies when required to help protect patients from harm.

Staff were aware of the need to protect people from discrimination and could describe how they supported patients with protected characteristics in line with the Equality Act 2010.

We reviewed 10 patient records. Records demonstrated that staff involved patients in identifying risks and discussing how these could be managed. Where risks were identified, staff worked with patients to agree appropriate strategies to reduce or manage them.

Risk assessments and management plans were reviewed when patients attended follow-up appointments, including medication reviews or changes to treatment.

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 premises where patients were seen were safe, clean, and suitable for the delivery of care. The main reception area, waiting rooms and consulting room were well maintained, appropriately furnished, and fit for purpose.

The provider's landlord had completed relevant risk assessments for the premises. Appropriate fire safety measures were in place, and fire exits were clearly marked. An automated external defibrillator (AED) was available for use in an emergency.

There was no clinic room on site as the service did not provide physical healthcare interventions requiring clinic facilities.

The provider completed safety risk assessments and had a range of safety policies in place. These policies were regularly reviewed, clearly outlined local procedures, and identified appropriate sources of advice and guidance for staff.

The service had qualified, skilled and experienced staff, who received effective support and supervision. They worked together well to provide safe care that met people’s individual needs.

The practice manager maintained a checklist for each member of staff working within the service. This provided oversight of key employment and professional requirements, including Disclosure and Barring Service (DBS) checks, mandatory training, and confirmation of professional revalidation with the relevant regulatory body, such as the General Medical Council (GMC). We reviewed all three staff files for employees working within the service. These records contained evidence that the required recruitment and employment checks had been completed. Staff files were well organised, clearly documented, and readily accessible.

Caseloads were managed appropriately to ensure clinicians had sufficient time to assess, support, and treat patients safely and effectively.

Staff had completed training in a range of areas, including basic life support for adults, safeguarding adults, equality and diversity, information governance, infection prevention and control, risk management, and General Data Protection Regulation (GDPR) requirements.

Clinicians had access to appropriate operational and administrative support from the practice manager.

Appropriate professional indemnity arrangements were in place. These arrangements provided insurance cover against claims arising from the day-to-day delivery of professional activities and services.

The provider had effective systems in place to manage infection prevention and control. Cleaning records demonstrated that daily cleaning checks were completed and that high-touch areas were cleaned regularly in line with expected standards. All areas of the service were clean, well furnished, and appropriately maintained

Staff used appropriate infection prevention and control measures to protect patients, staff, and visitors from the risk of infection. An infection prevention and control policy was in place to provide guidance for staff.

Hand sanitiser was available throughout the premises, including at the reception desk and in the clinician's consulting room, to support effective hand hygiene practices.

We found most practices relating to medicines optimisation were safe. There was one area where more work was needed to ensure consistency in line with best practice guidance.

For self-referring clients receiving prescriptions for mental health diagnoses, staff primarily relied on information about previous and current medicines from the person themselves. Staff did not always seek the person's consent to contact their GP to verify relevant medical information. Best practice guidance outlines that prescribers must ensure they have sufficient information to make safe prescribing decisions. This may include reviewing evidence such as repeat prescriptions, accessing information from a patient's summary care record where available, obtaining details from previous healthcare providers, or contacting the patient's GP when necessary. We saw that for patients referred directly from their GP or another healthcare professional, this information was shared in the referral documentation.

For patients prescribed medicines for attention deficit hyperactivity disorder (ADHD), records showed staff obtained and reviewed appropriate physical health information before treatment commenced, including electrocardiograms (ECGs) where indicated.

Where patients provided consent, records demonstrated that the service informed a person’s GP of new treatments and changes to prescribed medicines following consultations. The provider had assessed the risks associated with prescribing where information could not be shared with a patient's GP and had identified a range of medicines that would not be prescribed in these circumstances. These included medicines with a higher risk of misuse and medicines used to treat long-term physical health conditions.

The service had systems and procedures in place to support the safe management of repeat prescriptions and controlled drugs. Prescribing decisions were overseen by consultant psychiatrists with the appropriate skills, qualifications and experience.

Prescription stationery was stored securely, and the service maintained auditable records to demonstrate when prescription forms were issued to prescribers. The provider had implemented a repeat prescribing process which limited patients to one repeat prescription before a follow-up appointment with their clinician was required. Systems were in place for the secure management of controlled drug prescription stationery, supported by accurate records of its use and distribution.

The provider operated a service level agreement with two independent prescribing pharmacists who prescribed medicines on behalf of consultant psychiatrists. However, it was not clear from the records reviewed how patients were informed of this arrangement or whether explicit consent had been obtained for any associated sharing of personal information.

Records showed that staff routinely reviewed the effectiveness of medicines and monitored patients for side effects. Documentation reflected discussions about the impact of treatment on sleep, weight, concentration, mood, wellbeing, relationships and employment. Where patients reported no concerns or side effects, this was clearly documented. Where required, staff carried out physical health monitoring in line with relevant guidance.

No medicines were stored on site. Prescriptions were issued directly to patients or sent to a partner pharmacy.