• Organisation
  • SERVICE PROVIDER

Tavistock and Portman NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good

All Inspections

14 October 2020 to 6 November 2020

During an inspection of Gender identity services

This was an announced, focused inspection of the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust.

The Gender Identity and Development Service (GIDS) is provided by the Tavistock and Portman NHS Foundation Trust. In October 2020, the service was working with 2093 young people. The service is based at the Tavistock Centre in London. The service has a regional centre in Leeds and satellite clinics in Exeter, Bristol and Birmingham. Most of the referrals to the service are from GPs and child and adolescent mental health services. The service also accepts referrals from other health, social care and education professionals and from voluntary organisations. Referrals are made for people under the age of 18 with features of gender dysphoria. Gender dysphoria describes a sense of unease that a person may have because of a mismatch between their assigned sex at birth and their gender identity. The gender dysphoria leads to clinically significant distress and/or social occupational and other functioning impairment. There may be an increased risk of suffering distress or disability.

The service is commissioned by NHS England. The service is commissioned to provide assessments of young people, refer young people for medical treatment when appropriate and provide some continuing support when this is required. It is a national specialist service and is the only service available in England for children and young people with gender dysphoria. The service also treats children and young people from Wales.

The Tavistock and Portman NHS Foundation Trust provide outpatient psychosocial services only, and GIDS provides outpatient services for gender dysphoria. Any medical treatment is provided by other acute healthcare providers and the Tavistock and Portman NHS Foundation Trust refer into these as required. Medical treatment involves the prescribing of medicines that pause the physical changes of puberty and hormones that alter characteristics of gender. This medical treatment is provided by the endocrinology departments at University College Hospital London and Leeds General Infirmary. The CQC inspected and published reports on these services at the same time as the inspection and publication of GIDS.

Our last inspection of GIDS was in 2016. This took place as part of an overall inspection of the Tavistock and Portman NHS Trust. Following the inspection, we rated the trust as good overall. The domains of effective, caring, responsive and well-led were rated as good. The domain of safe was rated as requires improvement, although the improvements we said the trust must make related to a different service within the trust.

We undertook this inspection due to concerns reported to the CQC by healthcare professionals and the Children’s Commissioner for England. Concerns related to clinical practice, safeguarding procedures and assessments of capacity to consent to treatment. This inspection focused on the Gender Identity Development Service (GIDS) only.

As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent at the service to prevent cross infection. Four inspectors and a CQC specialist advisor visited the service at the Tavistock Centre on 14 and 15 October 2020 to review patients’ records and complete essential checks. Two inspectors visited the service in Leeds on 20 October 2020. Whilst on site we wore appropriate personal protective equipment (PPE) and followed local infection control procedures. The remainder of our inspection activity was conducted off-site. This included interviews by telephone, the use of video conferencing facilities and analysis of evidence and documents. Our final staff interview was completed on the 6 November 2020.

Separate from our inspection the High Court made a ruling on the 1 December 2020 around capacity and consent of children receiving hormone intervention for gender dysphoria. This ruling has not impacted on our findings. Our findings and judgements are based on the legal position at the time of our inspection.

Prior to, and during, the inspection we received intelligence from former members of staff and healthcare professionals not directly associated with the service. During the inspection visit, the inspection team:

  • visited the service to look at the quality of the environments
  • spoke with 22 young people who were using the service
  • spoke with 13 parents of young people using the service
  • reviewed information from 23 people who contacted the CQC through our website to share their experience of using the service
  • reviewed information from six people on the waiting list who contacted the CQC through our website
  • reviewed information from six service users and parents who wanted to share their experience via an independent organisation
  • spoke with four members of the GIDS clinical executive team, the GIDS safeguarding lead, the GIDS service manager, the divisional director for gender service, the medical director, human resources director and a staff governor.
  • spoke with 30 other staff members across the multidisciplinary team
  • looked at 35 patients’ records
  • looked at a range of policies, procedures and other documents relating to the running of the service.

Overall summary

Our rating of this service went down. We rated it as inadequate because:

  • The service was difficult to access. There were over 4600 young people on the waiting list. Young people waited over two years for their first appointment.
  • Staff did not always assess and manage risk well. Many of the young people waiting for or receiving a service were vulnerable and at risk of self-harm. The size of the waiting list meant that staff were unable to proactively manage the risks to patients waiting for a first appointment. For those young people receiving a service, individual risk assessments were not always in place with plans for how to manage these risks. The number of patients on the caseload of the teams, and of individual members of staff, were high making caseloads difficult to manage and placing pressure on staff.
  • Staff did not develop holistic care plans for young people. Records of clinical sessions did not include any structured plans for care or further action. Staff did not sufficiently record the reasons for their clinical decisions in case notes. There were significant variations in the clinical approach of professionals in the team and it was not possible to clearly understand from the records why these decisions had been made.
  • Staff had not consistently recorded the competency, capacity and consent of patients referred for medical treatment before January 2020. However, since this date these decisions had been recorded.
  • The teams did not always include the full range of specialists required to meet the individual needs of the patients. Staff did not always work well together as a multidisciplinary team.
  • Staff did not always feel respected, supported and valued. Some said they felt unable to raise concerns without fear of retribution.
  • The service was not consistently well-led. Whilst areas for improvement had been identified and some areas improved, the improvements had not been implemented fully and consistently where needed.

However:

  • Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. Feedback from young people and families currently being seen at the service was overwhelmingly positive about the care and support staff had provided.
  • Staff referred young people to other providers for medical treatments that were consistent with good practice.
  • Managers ensured that staff received training, supervision and appraisal. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Clinical premises where patients were seen were safe and clean.

Following the inspection, we took enforcement action against this provider under the Health and Social Care Act 2008 by imposing a condition upon their registration. This requires the trust to report to us on a monthly basis so we can monitor their progress with improving their waiting times.

13 August 14 August

During a routine inspection

However:

  • The monitoring of the quality and performance of the service lines was not sufficiently robust. At the time of the inspection, this took place through line management and an annual service line presentation to the board. Other governance systems looked across the service lines which could potentially lead to issues being missed or not given the focused attention they required.
  • The trust was working to implement a range of measures to improve career progression and address discrimination for black and minority ethnic (BME) staff. Some BME staff felt that these measures had not yet positively affected their experience of working for the trust. The trust leadership team recognised that this will take more time to fully embed.
  • The trust had experienced significant delays over the previous six months in responding to complaints relating to the gender identity clinic and had mostly missed the target for sending a response. Plans were in place to address this back-log. However, the complaint responses were of a high quality and showed empathy and a willingness to apologise where needed.
  • The trust was working to improve health and safety, including fire safety, across the trust, but this work needed to be completed and ongoing safety closely monitored to provide assurance.
  • People in GIC had long waits to access the service. They experienced a 13-month wait time for appointments and the service sometimes had to cancel and reschedule people’s appointment. The trust had tried to work with commissioners to increase funding but people still experienced long waits.

13 August to 19 September 2018

During a routine inspection

However:

  • The monitoring of the quality and performance of the service lines was not sufficiently robust. At the time of the inspection, this took place through line management and an annual service line presentation to the board. Other governance systems looked across the service lines which could potentially lead to issues being missed or not given the focused attention they required.
  • The trust was working to implement a range of measures to improve career progression and address discrimination for black and minority ethnic (BME) staff. Some BME staff felt that these measures had not yet positively affected their experience of working for the trust. The trust leadership team recognised that this will take more time to fully embed.
  • The trust had experienced significant delays over the previous six months in responding to complaints relating to the gender identity clinic and had mostly missed the target for sending a response. Plans were in place to address this back-log. However, the complaint responses were of a high quality and showed empathy and a willingness to apologise where needed.
  • The trust was working to improve health and safety, including fire safety, across the trust, but this work needed to be completed and ongoing safety closely monitored to provide assurance.
  • People in GIC had long waits to access the service. They experienced a 13-month wait time for appointments and the service sometimes had to cancel and reschedule people’s appointment. The trust had tried to work with commissioners to increase funding but people still experienced long waits.

13 August 14 August

During an inspection of Community-based mental health services for adults of working age

This was the first comprehensive inspection of this service. We rated it as good because:

  • The trust had improved the service since becoming the provider. At the last inspection in January 2016, governance processes at the service needed to improve. During this inspection, we found the trust had improved the governance and administrative processes.
  • Motivated and skilled staff with the right qualifications, skills, training and experience provided care and treatment based on national and international best practice and benchmarked against other similar services. People using the service could access specialist speech and language therapy, counselling and psychological therapies.
  • Staff cared for people who used the service with compassion. Feedback from people we spoke with and on comment cards confirmed that people felt staff treated them well and with kindness. Staff planned care together with people on an individual basis to ensure they accessed the treatments and support they needed.
  • The service worked with people’s GPs, and with endocrinology and surgery services, to support people to access the support they needed. The service worked closely with the trust’s adolescent gender identity development service to ensure young people transferred smoothly to the adult service.
  • The service made sure staff were competent for their roles. Staff completed mandatory training, and managers supervised and supported staff. The service had regular team meetings, a monthly multidisciplinary meeting and annual away days. The service supported staff with career development and progression.
  • Staff said the morale and culture of the service had greatly improved since the change in provider. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The service had a low staff sickness and vacancy rate.
  • Staff kept appropriate records of people’s care and treatment. Records were clear, up-to-date and available to all staff providing care. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff completed a range of audits and used the information to improve the service, for example the information included in first assessment reports and non-binary voice and communication.

However:

  • People waited a long time to access the service. At the time of the inspection, people waited 13 months from referral to initial assessment. The service had experienced a large increase in the number of referrals in the previous years, and the trust worked with commissioners to try and increase the funding for the service. However, the current funding combined with restricted working environment made it hard for the service to meet demand. The service still cancelled some appointments, but it had put in place a new system to rearrange cancelled appointments quickly.
  • The service did not ensure that important information was shared promptly following appointments. At the time of the inspection, the service took eight weeks to send letters to people using the service and health professional following appointments. We identified this at our previous inspection. The trust had shortened the time it took to send these letters, but it still needed to reduce the time further.
  • The service did not investigate and respond to people’s complaints within the 40-day extended timescale. Thirty-six out of 49 complaints in the last six months did not meet the target. The trust informed people when their complaint response would be delayed.
  • The service did not have robust systems in place to ensure fire safety. It had not completed a planned fire evacuation drill since January 2017.
  • Five people we spoke with said they would like better communication before their appointments and a reminder about their appointments. Eight comment cards also included feedback about the service improving communication regarding their appointments.
  • The service did not provide information in an accessible format for all people who may use the service.
  • The service had not updated their service user engagement strategy since the change in provider and had not organised any service user groups as identified in our last inspection.

13 August 14 August

During an inspection of Specialist community mental health services for children and young people

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff had manageable caseloads and responded to young people’s needs. Staff turnover and sickness for the team was low.
  • Staff had developed services based around the needs of young people. The service had worked with other providers to develop the THRIVE model for delivering CAMHS. This model aimed to deliver person-centred and integrated care based around the needs and preferences of young people and their families by promoting linked working between services.
  • Teams worked well with other services both within the trust and externally to provide a consistent and seamless service to children, young people and their families. For example, CAISS staff worked closely with emergency department staff to support young people presenting at the local general hospital with mental health deterioration, and CAMHS practitioners provided sessions to young people in schools. Staff were flexible and offered appointments outside of traditional office hours if required and in a range of venues.
  • Young people and families said that the services had been helpful to them and this was reflected in feedback surveys that services collected each month. Staff involved families and carers, for example the service conducted a six-week psychoeducation group for them to help them better understand the difficulties young people may face.
  • Teams were very responsive and saw young people and their families in a timely manner. The average waiting time between referral to assessment and assessment to treatment was low at three weeks. Service managers screened referrals to ensure urgent referrals were seen quickly. The waiting rooms at Camden CAMHS south and north were bright, colourful and spacious.
  • Staff were very positive about their teams, said that they felt supported by colleagues and managers and that everyone was dedicated to supporting young people who accessed their services. Leadership development opportunities were available for managers and staff below team manager level. The trust was committed to improving services by promoting training, research and innovation.
  • The trust had set up the Camden adolescent intensive support service to work with 11-18 year olds and their families who experienced a significant deterioration in their mental health to prevent tier 4 admission. Managers analysed performance data that demonstrated young people of Camden were spending 48% less time in tier 4 psychiatric hospitals since CAISS was set up.
  • Since the last inspection in January 2016, the trust had successfully addressed most of the areas needed for improvement. This included ensuring staff shared crisis plans with young people, providing information leaflets on how to complain, ensuring staff recorded information about young people on the electronic patient record systems, and ensuring all young people had a clear plan of care and treatment in care records.

However:

  • Since the last inspection in January 2016, the trust had not successfully addressed three areas needed for improvement. This included failing to demonstrate regular cleaning of toys used by children, staff not ensuring that all young people having risk assessments in place, and teams not providing information in accessible formats for younger children.
  • The service did not have a system in place to ensure front-line staff had opportunities to learn from incidents, audits and complaints. They did not have access at a team level to the risk register to directly report risks or see what action was being taken.
  • The staff needed the improve the safety of the environment. The current procedure for ensuring staff safety when seeing patients alone for therapy on site in the event of an emergency was not robust. Fire safety systems at both sites were not robust.
  • Not all staff were clear about which incidents needed to be formally reported.
  • Administration staff did not have access to one-to-one supervision, which meant they did not have protected regular time to meet with their manager to discuss well-being or career development.
  • Staff’s knowledge of the Mental Capacity Act varied between teams. Some staff were unfamiliar with how they would apply the legislation in practice.
  • IT systems could not always be accessed by clinicians when they were offsite. This meant staff had to travel back to the team office to update patient records, which was a time-consuming task.

13 August to 19 September 2018

During an inspection of Specialist community mental health services for children and young people

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff had manageable caseloads and responded to young people’s needs. Staff turnover and sickness for the team was low.
  • Staff had developed services based around the needs of young people. The service had worked with other providers to develop the THRIVE model for delivering CAMHS. This model aimed to deliver person-centred and integrated care based around the needs and preferences of young people and their families by promoting linked working between services.
  • Teams worked well with other services both within the trust and externally to provide a consistent and seamless service to children, young people and their families. For example, CAISS staff worked closely with emergency department staff to support young people presenting at the local general hospital with mental health deterioration, and CAMHS practitioners provided sessions to young people in schools. Staff were flexible and offered appointments outside of traditional office hours if required and in a range of venues.
  • Young people and families said that the services had been helpful to them and this was reflected in feedback surveys that services collected each month. Staff involved families and carers, for example the service conducted a six-week psychoeducation group for them to help them better understand the difficulties young people may face.
  • Teams were very responsive and saw young people and their families in a timely manner. The average waiting time between referral to assessment and assessment to treatment was low at three weeks. Service managers screened referrals to ensure urgent referrals were seen quickly. The waiting rooms at Camden CAMHS south and north were bright, colourful and spacious.
  • Staff were very positive about their teams, said that they felt supported by colleagues and managers and that everyone was dedicated to supporting young people who accessed their services. Leadership development opportunities were available for managers and staff below team manager level. The trust was committed to improving services by promoting training, research and innovation.
  • The trust had set up the Camden adolescent intensive support service to work with 11-18 year olds and their families who experienced a significant deterioration in their mental health to prevent tier 4 admission. Managers analysed performance data that demonstrated young people of Camden were spending 48% less time in tier 4 psychiatric hospitals since CAISS was set up.
  • Since the last inspection in January 2016, the trust had successfully addressed most of the areas needed for improvement. This included ensuring staff shared crisis plans with young people, providing information leaflets on how to complain, ensuring staff recorded information about young people on the electronic patient record systems, and ensuring all young people had a clear plan of care and treatment in care records.

However:

  • Since the last inspection in January 2016, the trust had not successfully addressed three areas needed for improvement. This included failing to demonstrate regular cleaning of toys used by children, staff not ensuring that all young people having risk assessments in place, and teams not providing information in accessible formats for younger children.
  • The service did not have a system in place to ensure front-line staff had opportunities to learn from incidents, audits and complaints. They did not have access at a team level to the risk register to directly report risks or see what action was being taken.
  • The staff needed the improve the safety of the environment. The current procedure for ensuring staff safety when seeing patients alone for therapy on site in the event of an emergency was not robust. Fire safety systems at both sites were not robust.
  • Not all staff were clear about which incidents needed to be formally reported.
  • Administration staff did not have access to one-to-one supervision, which meant they did not have protected regular time to meet with their manager to discuss well-being or career development.
  • Staff’s knowledge of the Mental Capacity Act varied between teams. Some staff were unfamiliar with how they would apply the legislation in practice.
  • IT systems could not always be accessed by clinicians when they were offsite. This meant staff had to travel back to the team office to update patient records, which was a time-consuming task.

13 August to 19 September 2018

During an inspection of Gender identity services

This was the first comprehensive inspection of this service. We rated it as good because:

  • The trust had improved the service since becoming the provider. At the last inspection in January 2016, governance processes at the service needed to improve. During this inspection, we found the trust had improved the governance and administrative processes.
  • Motivated and skilled staff with the right qualifications, skills, training and experience provided care and treatment based on national and international best practice and benchmarked against other similar services. People using the service could access specialist speech and language therapy, counselling and psychological therapies.
  • Staff cared for people who used the service with compassion. Feedback from people we spoke with and on comment cards confirmed that people felt staff treated them well and with kindness. Staff planned care together with people on an individual basis to ensure they accessed the treatments and support they needed.
  • The service worked with people’s GPs, and with endocrinology and surgery services, to support people to access the support they needed. The service worked closely with the trust’s adolescent gender identity development service to ensure young people transferred smoothly to the adult service.
  • The service made sure staff were competent for their roles. Staff completed mandatory training, and managers supervised and supported staff. The service had regular team meetings, a monthly multidisciplinary meeting and annual away days. The service supported staff with career development and progression.
  • Staff said the morale and culture of the service had greatly improved since the change in provider. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The service had a low staff sickness and vacancy rate.
  • Staff kept appropriate records of people’s care and treatment. Records were clear, up-to-date and available to all staff providing care. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff completed a range of audits and used the information to improve the service, for example the information included in first assessment reports and non-binary voice and communication.

However:

  • People waited a long time to access the service. At the time of the inspection, people waited 13 months from referral to initial assessment. The service had experienced a large increase in the number of referrals in the previous years, and the trust worked with commissioners to try and increase the funding for the service. However, the current funding combined with restricted working environment made it hard for the service to meet demand. The service still cancelled some appointments, but it had put in place a new system to rearrange cancelled appointments quickly.
  • The service did not ensure that important information was shared promptly following appointments. At the time of the inspection, the service took eight weeks to send letters to people using the service and health professional following appointments. We identified this at our previous inspection. The trust had shortened the time it took to send these letters, but it still needed to reduce the time further.
  • The service did not investigate and respond to people’s complaints within the 40-day extended timescale. Twenty-eight out of 53 complaints in the last six months did not meet the target. The trust informed people when their complaint response would be delayed.
  • The service did not have robust systems in place to ensure fire safety. It had not completed a planned fire evacuation drill since January 2017.
  • Five people we spoke with said they would like better communication before their appointments and a reminder about their appointments. Eight comment cards also included feedback about the service improving communication regarding their appointments.
  • The service did not provide information in an accessible format for all people who may use the service.
  • The service had not updated their service user engagement strategy since the change in provider and had not organised any service user groups as identified in our last inspection.

24 - 25 November 2016

During an inspection looking at part of the service

We have given an overall rating to Tavistock and Portman NHS Foundation Trust of good. We have rated the three services that we inspected as good.

  • At the last inspection in January 2016, we rated the specialist community mental health services for children and young people and other specialist services (gender identity development service) and as good in all areas.

  • At the last inspection in January 2016 we rated specialist psychological therapy services as good in four of the five domains including caring, effective, responsive and well-led. We rated safe as requires improvement. During this inspection we found that the trust had addressed the three issues leading to this rating and therefore changed the rating of safe to good. The issues from the January 2016 inspection were the use of crisis plans, risk assessments and management plans and having a separate waiting area for people under 18 at the Portman Clinic.

24 - 25 November 2016

During an inspection of Specialist psychological therapy services

We rated specialist psychological therapy services as good overall because:

  • Following our inspection in January 2016, we rated the services as good for effective, caring, responsive and well led.

  • During this inspection we found that the trust had addressed the issues that had caused us to rate safe as required improvement. These were the completion of crisis plans and risk assessments and having a separate waiting area for people under 18 at the Portman Clinic.

25 - 29 January 2016

During a routine inspection

We have given an overall rating to Tavistock and Portman NHS Foundation Trust of good.

We have rated the three services that we inspected as good.

The trust has much to be proud of and also some areas that need to improve. The trust was well-led by the senior leadership team and board. There were many committed and enthusiastic senior staff throughout the organisation working hard to improve the delivery of psychological therapies, provide innovative services and national specialist services to children, young people and adults in out-patient and community settings.

The main areas which were positive were as follows:

  • We spoke with very caring staff in all of the services and teams we visited. They were clearly sighted on and understood the needs of patients they worked with. We received a lot of very positive feedback from patients and parents about staff.
  • There were several excellent examples of staff working in partnership with other organisations such as local schools, GPs and health visitors.
  • Staff were receiving very regular supervision, which they felt was of high quality. Staff were up to date with mandatory training and described significant opportunities for further professional development. All staff received an annual performance appraisal.
  • The staff provided patients with good quality psychological therapies. The psychological therapies provided were evidence-based. Some teams were undertaking innovative projects to enhance patient care and treatment or were involved in research.
  • Most staff had a good understanding of safeguarding policies and procedures in respect of both children and vulnerable adults.
  • The trust had recognised particular areas of local need and developed services to help meet those needs. For example, the excellent work with refugee communities.
  • Staff and managers had worked to address equality and diversity issues in the trust work force as well as improve access to psychological therapies for under-represented groups.
  • The trust had developed a number of creative and innovative initiatives aimed at involving patients in services and service development.
  • There were very high levels of job satisfaction amongst staff in all teams we visited and in the trust as a whole.

There were some areas which needed improvement. The main areas for improvement were as follows:

  • The documentation in relation to the risk assessment and risk management of patients was sometimes poor, particularly in the Portman clinic. Assessments did not always reflect actual risks. The local network involved in managing risks affecting patients was not always identified. Patients did not always have clear crisis plans in place that staff could find quickly in an emergency. Risk registers did not extend to team level which meant there was a risk that not all risks were being captured and reported at board level. In the Portman clinic adults and children and young people shared a waiting room. Despite mitigating action taken by the trust, this was not appropriate and potentially unsafe, especially given the risk histories and previous experiences of patients attending the clinic.
  • Services were struggling to implement the new electronic patient records system. Some services were keeping both paper and electronic records for the same patient, some paper records were poorly scanned making them difficult to read, and one service had not yet implemented the electronic patient record system. There were risks to patient care from running paper and electronic records systems side by side. The quality of data extracted from the system was unreliable.
  • The physical health needs of patients were not made a high priority. We noted the trust had recruited a physical health nurse one day a week, and was recruiting another, to improve the support offered to patients around smoking and alcohol use in particular. However, it was not clear that staff always considered the wider physical health needs of patients.
  • The trust had not carried out infection prevention and control risk assessments in all premises where patients were seen. This meant the trust could not be confident that all infection risks were being managed appropriately.
  • The trust had recently contracted a new independent advocacy provider. However, staff and patients were generally unaware of the service and we saw no advertising of the service in the areas we visited.
  • There was much creative and innovative work taking place in the trust. However, there was a lack of agreed strategy or frameworks in place to support continuous improvement and ensure sustainability.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

25 - 29 January 2016

During an inspection of Specialist community mental health services for children and young people

We rated Tavistock and Portman NHS Foundation Trust specialist community child and adolescent mental health services as good because:

  • Compliance with mandatory training, supervision and appraisals was high and levels of staff turnover and sickness were low. There were excellent opportunities for training and development. All staff were trained in safeguarding children level three and had a clear understanding of safeguarding procedures. Staff had a good understanding of NICE guidance and each team had a NICE champion who kept them up to date with the latest guidance. Most staff understood how to report incidents. The number of serious incidents was very low.

  • Services were meeting the target time of 11 weeks from referral to assessment and were usually completing assessments in less than eight weeks. Service managers ensured urgent referrals were seen quickly. Staff described effective communication and referrals between services, such as local schools, GPs and health visitors.

  • The refugee service had a diverse staff group with a rich breadth of experience and cultural competence within the team. The service had done a lot of work to engage with hard-to-reach communities and families. The trust was involved in a project to provide services to young people aged between 16 and 24 who may have difficulty with transferring to adult services.

  • Staff had good understanding of issues of consent and Gillick competence in their work with young people.

  • All parents and young people said staff listened to them, were caring, open, positive and respectful. They found the service very helpful and described many positive changes that treatment had brought about. Parents could easily contact staff and Staff used a range of outcome measures with young people and parents.

  • The trust website provided clear information about each service and contacts for self-referral. Waiting rooms for young people and adolescent across all sites were bright, colourful and spacious.

  • Staff felt that colleagues valued each other and trainees told us that the wider team were aware of their role and that colleagues were supportive of them. Staff said they enjoyed and felt proud to work for the organisation and felt the trust had a strong identity.

However:

  • Not all young people had an up to date current risk assessment present in their care records. Not all patient records contained accurate, up-to-date and complete information about the young person’s plan of care. Staff were struggling to use the new electronic patient care record system. There were inconsistencies in the recording of information, staff did not always know where to record information and it was difficult to read historical information recorded prior to the change in records system.

  • Staff were not always clear how they should share crisis plans with young people and their parents. Some young people and parents were not aware who they should contact in a crisis.

  • There was no formal schedule for cleaning toys to reduce the risk of spread of infection between young people who used the toys.

  • Staff did not routinely assess young people’s physical health. Staff assessed smoking and alcohol intake for young people over the age of 14, although not all records contained these assessments.

  • Most parents, young people and staff were not aware of the independent advocacy service. The advocacy service was not advertised in waiting rooms. Information about how to complain was not available in waiting rooms for young people. Information was not readily available in accessible formats for younger children or for young people with learning disabilities.

25 - 29 January 2016

During an inspection of Specialist psychological therapy services

We gave an overall rating for specialist psychological therapy services as good because:

  • The staff provided patients with good quality psychological therapies. Therapists were well qualified and experienced.Therapists undertook a comprehensive assessment of each patient at the initial assessment and corresponded regularly with referrers. The psychological therapies provided were evidence-based. The City and Hackney primary care psychotherapy consultation service (PCPCS) had won a major award in 2015 for their creative approaches to working with people with medically unexplained symtpoms. The PCPCS provided groups tailored to the needs of the local Turkish speaking population and other black and ethnic minority groups who traditionally did not use psychological therapies. Some teams were undertaking innovative projects to enhance patient care and treatment or were involved in research.

  • Despite high demand, the services generally managed patient referrals well. Staff assessed most patients promptly. When this was not possible, staff reviewed patients who were waiting and offered support. Teams took action to follow up patients who did not attend appointments.

  • The trust supported staff well. This was reflected in the annual staff survey which showed that the trust scored amongst the top 20% of trusts on most measures. There were few vacancies, a low staff turnover and low rates of staff sickness. Managers ensured that staff received ongoing specialist training, supervision, appraisal and professional development.

  • Most patients had positive experiences of care. Staff were caring, friendly and dedicated and gave patients opportunities to engage in groups and provide regular feedback to the trust about their experience. Few patients complained about the service.

  • The services had a good safety record. There had been very few incidents in the last 12 months. Staff knew how to report incidents. The trust highlighted lessons learned from incidents in the quality newsletter, at mandatory in-service training sessions and at team meetings. The care environments were safe, well maintained and visibly clean.

  • Overall the teams were well-led and managers were very experienced.

However:

  • Risk assessments and risk management plans were not always robust. At the Portman clinic, which cared for the most high risk patients in the trust, care records lacked vital information about the risks affecting patients and how the risks were being safely managed. This lack of information put staff and others at risk. Care records lacked important correspondence from external agencies. In some services patients did not always have individual crisis plans to mitigate risks to patients in a crisis readily available to staff

  • The Portman clinic did not offer separate waiting rooms for children and adults. Due to the nature of the service and the background of the patients that attended the clinic, a shared waiting room put young adults and children at risk of harm. Despite mitigating action taken by the trust, this was not appropriate and potentially unsafe.

  • The provider had not carried out infection prevention and control risk assessments in premises where patients were seen.

  • Not all teams were using the new electronic patient records system. Records of children and young people using services at the Portman clinic did not demonstrate that issues of capacity or Gillick competence had been discussed or assessed.

  • The Portman clinic was not accessible to people with disabilities who would benefit from group therapy. Individual therapy could be offered in another building.

25 - 29 January 2016

During an inspection of Other services

We rated the gender identity development service as good because:

  • Children and young people received care delivered by a skilled multi-disciplinary team who were supported to develop specialist skills and knowledge.

  • Managers provided staff with frequent and effective supervision and supported the staff team through regular meetings, appraisal and reflective practice groups. The team was cohesive and proud to work for the trust.

  • Most young people and family members were extremely positive about the support which they received from the service.

  • The service worked to address risk and recognised safeguarding concerns where they arose.

  • There was a very strong focus on research and using evidence based practice as well as extending the research base and evidence within this specialist area. Clinicians had opportunities to attend and contribute to international conferences and publish research findings. They also carry out service-specific audits with a focus on improving the outcomes for children, young people and families who used the service.

However:

  • While staff understood the importance of risk assessment and management and told us they reviewed risks regularly, this was not always recorded in detail in young people’s records.

  • Some parents told us that they did not receive clear information about the pathway, and care and treatment plans within the service.

  • There had been some breaches of the 18 week waiting time between referral and assessment. The number of breaches had increased over the past year due to the increase in referrals.

  • Some parents and carers were reluctant to make a complaint as they feared this would affect the treatment of their child. We found no evidence to suggest this was the case but staff had not been proactive in encouraging complaints or providing reassurance.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.