3 The Beeches

Updated 12 March 2024

3 The Beeches is a location run by Sanctum Healthcare Limited. It provides a community assessment service for attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). It offers a treatment package for people who receive a confirmed diagnosis of ADHD or ASD. The service model had changed in early 2022 to focus solely on these pathways. The provider offered their services to people from the ages of 6 and above.

The location was registered with CQC on the 14th March 2022; although the provider had originally been registered with CQC on the 19th February 2019.

The service had a Registered Manager.

The service is registered by the CQC to provide the following registered activities:

• Diagnostic and screening procedures.
• Treatment of disease, disorder or injury.

This was the first inspection of the service. During this inspection we inspected all key questions across this core service. This inspection was short notice announced due to the service being based in the community and due to its small size.

What people who use the service say

We spoke with 5 patients who had accessed the service. Patients gave positive feedback about the quality of care and treatment they had received. Patients described staff as kind, caring and responsive to their needs.

We spoke with a patient who had made a complaint to the service. This patient reported they were happy with how their complaint had been dealt with and could see that the service had made changes in response to their complaint.

We also spoke with 2 family members or carers of people using the service. Families were very positive about the service and their interactions with staff.

Updated 12 March 2024

This was the first inspection for this location. We rated it as requires improvement because:

• The service did not have robust governance processes that provided appropriate assurance to managers about the safety and effectiveness of the service.
• There were a number of policies awaiting review or in the process of being reviewed. These had not been updated in line with the change in service model or to reflect the current organisational structures or leadership. It was not always clear about who had certain specific responsibilities within the organisation.
• The service did not have a vision and values underlying the work being undertaken by the service and staff; that would support the consistency of responses and services being provided to patients.
• The service did not have processes for routinely gathering patient and family feedback about the service or their experiences of assessment and treatment.
• The service had not developed outcomes or key performance indicators that they routinely reviewed or reported on, although patient progress was tracked on an individual level.
• Formal supervision records were not being kept and there was no evidence as to how frequently supervision had been taking place. It was not clear how the service was supporting staff with continuous professional development.
• The service did not have appropriate first aid arrangements within the building as per the minimum requirements set out by the Health and Safety Executive in respect of first aid. The service did not have all appropriate health and safety assessments to ensure any risks associated with the building were being managed.

However:

• Patients gave positive feedback about staff and their experiences of the service. Patients felt the staff were responsive. Staff were attentive to patients and families when they contacted the service and responded to patients in a kind and pleasant manner.
• During assessments, Families were being involved in assessments and could provide their input and opinion.
• There was evidence of ongoing review of patients using monitoring tools to review the individual’s progress and development.
• The service utilised patient background and feedback as part of the assessment process; gathering information from additional sources where possible.
• The service had begun to develop clinical governance meetings which reflected the beginning of positive change regarding governance. Managers were open and honest about the limitations of the service in this area.

Updated 12 March 2024

We rated the service as requires improvement. See the summary above for details.