14 Harley Street

On this page

• 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

This was our first inspection of this service, and we rated this key question Good. This meant people were safe and protected from avoidable harm.

• All premises where clients received care were safe, clean, well equipped, well furnished, well maintained and fit for purpose.
• Risks were assessed and managed well. The service had a very clear scope of practice and ensured it referred people to alternative services if it could not safely meet their needs.
• Staff kept up-to-date records of clients’ care and treatment and stored these in line with privacy and confidentiality requirements.

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 had a vision and commitment to delivering person-centred, mental health care. Staff were able to describe and demonstrate the provider’s vision and values in their work. 

Staff told us that the team worked well together.

All staff had the opportunity to contribute to discussions about the strategy of the service, especially where the service was changing.

Staff said they felt respected, supported and valued. During interviews all staff said they felt proud to work at the service.

The service had an equality and diversity policy in place that staff were aware of. All staff had completed mandatory training in relation to equality and diversity. They said the provider promoted equality and diversity and provided opportunities for development.

All staff said they could raise any concerns without fear.

The consultant psychiatrists had the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty. All the staff had a good

understanding of the service they delivered, and the doctors were visible and approachable to their team.

The registered manger had the skills, knowledge and experience to perform their role. They had a good understanding of the services they managed and were visible in the service and approachable for patients and staff.

Staff told us that they would have no hesitation in whistleblowing if they had concerns about the service. Staff were aware of how to do this internally and externally. 

The provider worked towards an inclusive and fair working culture. All staff we spoke to stated that they felt respected and valued.

Staff received training on equality, diversity and inclusion.

No staff said they had experienced bullying, harassment or discrimination at work. 

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care and treatment. The service acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a clear framework of service meetings and items to be discussed. This ensured essential information, such as changes, developments, learning from incidents and complaints, was shared. Governance meetings were held on a monthly basis.  

The service had implemented recommendations from reviews of incidents, and safeguarding at the service level where appropriate.

Staff participated in clinical audits. The audits provided assurance and staff acted on the results when needed. 

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.

Information governance systems included confidentiality of patient records. The registered

manager used tools provided by the information commission office to ensure the way the

service stored personal information met national standards. All portable devices used within the service such as laptops were encrypted and required a two-step verification process to access them.

The provider ensured all information was archived. The registered manager had put arrangements in place to manage records containing personal information if the provider ceased to trade.

During our recent inspection, all the service policies in date and were available to each member of staff on the shared system.

The service had plans for emergencies and implemented contingency plans when needed.

The service had a risk register in place. This included considerations of risks relating to clinical risk assessment and management, medicine management issues, infection control issues, serious incidents, alcohol hand gel fire risk and health and safety of the environment.

We found one area where improvement was needed. Staff members did not have two

references within their employment records, which they should have done. We highlighted this at the time of the inspection. 

The service had developed links with external services where it could refer patients for support, where the service was not best placed to meet their needs. This was made clear to clients when they accessed the service.

Teams had access to the information they needed to provide safe and effective care and used that information to good effect.

The consultant psychiatrist focused on continuous learning, innovation and high-quality care being delivered both within and outside of their service. In addition to their clinical work at the service, they actively participated and contributed to safe and effective practice.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. For example, following a serious incident, the team identified the need for structured space to reflect on difficult cases. As a result, the service introduced facilitated reflective practice.  

There were no specific national accreditation schemes for the service to participate in.

However, the psychiatrist ensured his own clinical practice was reviewed externally on a regular basis and participated in other activities to ensure care and treatment provided was effectiveness.