Outpatient Services

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score:3

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff were trained in incident reporting and understood what needed to be escalated, they reported when they should. There had been 7 serious incidents at the service in the last 12 months. Incidents we reviewed were well managed.

Staff told us they felt comfortable raising concerns and had access to debrief support when needed.

Learning from safeguarding incidents was shared across the services through a variety of meetings and communication methods.

All staff we spoke with could describe learning from recent incidents and how it had been shared in team meetings. There was evidence of changes being made as a result of feedback. Staff received feedback from investigation of incidents, both internal and external to the service.

The service had a system for reviewing incident trends, which led to minor changes in room booking protocols and lone-working arrangements.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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.

The service’s referral processes ensured that sufficient information was provided in advance to assess whether needs could be safely met.

Staff had access to clinical and safeguarding histories before offering appointments, supporting safe triage.

Risk assessments were carried out prior to treatment, and information was shared appropriately with referring teams, including primary care and statutory services.

Where care was shared across settings (e.g. for autism assessments or trauma work), staff engaged with relevant professionals to ensure continuity and reduce duplication.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

At the time of our assessment, 98% of staff received safeguarding training relevant to their roles and knew how to identify and report concerns in relation to adults and children.

There was a designated safeguarding lead who staff could contact for advice and escalation.

Safeguarding concerns were recorded and referred appropriately, with oversight maintained through regular governance meetings.

One safeguarding concern we reviewed detailed concerns regarding inappropriate boundaries between a staff member and patient. We found that appropriate action was taken to reduce the risk of ongoing harm, including robust investigation and liaison with safeguarding partners.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were comprehensive, personalised and developed in partnership with service users.

Records showed that individuals were consulted about what safety meant for them, particularly in relation to managing trauma-related symptoms and transitions between sessions.

Staff supported people to identify coping strategies and early warning signs in their own language.

Consent and safety plans were revisited regularly during therapy to ensure people felt in control and could adjust support as needed.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients. For example, by providing different formats for people whose first language was not English.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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 outpatient service was located in a standalone, accessible building with a secure entry system and clearly signposted therapy rooms.

There were appropriate facilities for visitors, including a waiting area, refreshments, and assisted toilets.

Therapy rooms were clean, welcoming, and designed to promote a calm therapeutic atmosphere.

Health and safety checks were carried out regularly, and staff followed infection prevention and control measures in line with national guidance.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made 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.

The service included a team of approximately 90 people, with 76 of those people working remotely. The service were considering additional roles that might support their service development. For example, they were looking at the benefits of creating a post for an autism assessor and additional psychologists.

Staff had the appropriate training, skills and knowledge for the outpatient model, with therapists, psychologists, and administrative staff in post.

There was no reliance on agency staff at this location, and continuity of care was maintained across booked sessions. However, they did maintain a bank of associates to support with extra assessments where necessary.

Mandatory training compliance was monitored including ILS and BLS. All mandatory training was above 93%.

There were systems in place to manage lone working, including risk assessments and check-in protocols. This included the use of an app called ‘People Safe’ for staff who were designated lone workers.

Prevention and Control

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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 environment was visibly clean and well maintained, with cleaning schedules in place and monitored.

Hand hygiene stations were available throughout the building, and PPE was used appropriately.

Staff followed infection control procedures aligned with best practice, including protocols for room cleaning between sessions. Staff adhered to infection control principles, including handwashing. IPC training compliance was 100%.

The service had an infection control lead, and audits were conducted periodically to maintain compliance.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service did not manage or store any medications on site. There were no medication stocks, controlled drugs, or emergency medicines held at the location.

Prescriptions that were issued by the service were managed safely, with appropriate clinical oversight, record-keeping and adherence to safe prescribing best practice guidelines.