18 October 2023
During a routine inspection
This service is rated as Good overall. (Previous inspection 01 2018 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
We carried out an announced comprehensive inspection at The Child and Family Practice as part of our inspection programme.
The service provides outpatient mental health assessments and treatment for children and adults.
The consultant psychiatrist at the service is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The inspection of The Child and Family Practice focused on the clinical treatment delivered by the consultant psychiatrist and the associated administrative support. The inspection did not look at the treatment delivered by the other clinicians who rented rooms at this location to see patients. They were either separately registered or had practising privileges with another registered provider.
Our key findings were:
- The service met the needs of the individual patients who were assessed and treated.
- Each patient had a comprehensive mental health assessment. The treatments provided were informed by best-practice guidance and suitable to the needs of the patients.
- The service considered the risks for individual patients and understood and acted appropriately to safeguarding concerns.
- Staff worked well together as a team and linked with relevant services outside the organisation such as the patients GP.
- Staff had access to mandatory training and supervision.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. The service actively involved patients and their families in care decisions.
- The service was easy to access. Every referral received a telephone response, discussing whether the service could meet their needs or not. The service actively sought patient feedback on care.
- The service promoted a positive, patient centred culture. Leaders were competent, accessible and supportive.
However:
- Staff employment records did not include all the required information.
CQC inspected the service in January 2018 and asked the provider to make improvements regarding access to patient records belonging to other faculty members. This was not identified as a concern at this inspection because faculty members operated as independent healthcare professionals. This means that there is no requirement for them to access each other’s treatment records for the purpose of shared governance processes.
The areas where the provider must make improvements as they are in breach of regulations are:
- The service must ensure governance arrangements identify when areas for improvement are needed. This included ensuring staff pre-employment checks were completed and documented.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- The service should ensure consent to treatment is formally recorded for all patients in the patient record.
- All staff should receive an annual appraisal.
- The service should ensure policies and procedures are dated and version controlled.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services