Phoenix Mental Health Services - The Alec Forti Rooms

This service is rated as Requires improvement overall.

Phoenix Mental Health Services - The Alec Forti Rooms were previously inspected in 2013 under Essential Standards and the Health and Social Care Act 2008 (Regulated Activities) Regulations 82014 (Part 3). The service was deemed to have met the standard at this inspection.

This is the first rated inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at The Alec Forti Rooms as part of our programme and in response to a Direct Monitoring Approach.

CQC (Care Quality Commission) inspected the service on 6-7 March 2013 and at the time of the inspection the provider met the compliance standards.

The service is a private clinic providing outpatient assessment and treatment to people referred by their General Practitioners or legal representatives. People attending the clinic were also able to self-refer for assessment and treatment. The service specialises in adult and child psychiatry. Most of the staff are associates.

The clinical director 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.

We spoke with 6 patients to gain their feedback about the service.

Patients praised the staff for their efficiency and professionalism. They felt safe to share details about their mental health needs but were not always confident that their personal information would be kept private. For example, there were occasions when information was shared to insurance companies or GP (General Practitioner) despite request not to disclose some information.

There was a clear assessment process and the service offered flexibility of appointments. There were clear on the reasons for the referral and the treatment they were having. Patients were copied into emails about the outcome of their appointments.

Patients were not aware of any system to give feedback about the service.

Our key findings were:

• The service ensured patients consented to the treatment to be provided.
• Patients were copied into emails to their GP which detailed their treatment options.
• The service responded promptly to referrals for treatment.

However :

• There was a lack of oversight across the service. There was no system for monitoring the service. For example, a clinical audit programme.
• Policies and procedures were not in place on the standards of the service or how they were to be managed. Where policies were in place, some were outdated or not reviewed within an appropriate timeframe.
• While risks had been assessed, they lacked detailed plans on how the risks were to be reduced.
• Clinical associated training records and checks of professional qualifications were not currently kept.
• Clinical associates were not having regular supervision to ensure they met the values of the service.

The areas where the provider must make improvements as they are in breach of regulations are:

• The provider must ensure that policies and procedures on the standards of the service and how they are to be managed and reviewed are in place. For example, safeguarding of adults and children. Regulation 17
• The provider must introduce a governance system to monitor the quality performance of the service. The provider must also confirm the professional qualifications and training of clinical associates. Regulation 17
• The provider must ensure risk assessments detail how risks will be mitigated which must be reviewed. Where physical health checks are advised the provider must ensure good practice guidance is followed. Regulation 12
• The provider should ensure clinical associates have regular supervision to ensure they meet the values of the service Regulation 18

The areas where the provider should make improvements are:

• The service should introduce surveys on patients experience of their treatment.
• The provider should ensure learning from incidents and accidents is shared.