Tavistock and Portman NHS Foundation Trust

Updated 13 December 2023

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.

Updated 10 May 2023

We carried out this short notice announced, focused inspection in line with our inspection methodology. As this was a focussed inspection, we have not rated the service.

At our last inspection visit in 2016 we rated the Portman clinic overall as good and requires improvement in safe. This inspection included a follow up on our last inspection to see if improvements had been made.

During this inspection we looked at three key lines of enquiry. We looked at safe, responsive, and well led.

The Tavistock and Portman NHS Foundation Trust provides specialist psychological therapy services. The Portman clinic provides outpatient assessment and treatment to both adults and children. The Portman clinic provides assessment and treatment for patients primarily presenting with difficulties relating to violence and sexual compulsions. Using psychoanalytically informed psychotherapeutic help to provide services for people who may be excluded from other services due to their past or present behaviours.

The clinic offers individual therapy, group therapy and occasionally couples therapy. They also offer a mentalisation-based treatment programme for men with a diagnosis of antisocial personality disorder which comprises of group and individual sessions.

The staff are trained as psychoanalysts, psychoanalytic / psychodynamic psychotherapists, child and / or adolescent psychotherapists with backgrounds in nursing, psychiatry, psychology, probation and social work.

Five months before our inspection, the trust had experienced a malware attack effecting the trust’s electronic patient record system. We took this into account during our inspection and assessed how the service had managed this. This issue had affected several NHS and independent health providers.

We did not rate this service at this inspection. The previous rating of good remains. We found:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service managed infection risk well. Staff assessed risks to patients and acted on them. The service managed safety incidents well and learned lessons from them.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their care and treatment. They provided emotional support to patients, families, and carers.
• The service took account of patients’ individual needs and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. At a service level, staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

However:

• Although there were overall improvements since our last inspection, adult case records sometimes lacked consistency in case recording and completion of risk documentation.
• Staff survey results indicated there was significant work needed to address staff morale and wellbeing as scores were lower than the trust average in several key areas.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about the location.

As part of the inspection, the inspection team:

• Visited the clinic and looked at the quality of the environment
• Spoke with 7 people who were using the service
• Spoke with 16 staff including the service manager, clinical lead, administration, and therapy staff
• Looked at 25 care and treatment records
• Looked at a range of policies, procedures and other documents relating to the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with patients during our inspection and the feedback was overwhelmingly positive. Patients said that the treatment had changed their lives for the better and helped them understand themselves better.

Patients told us all the staff treated them with kindness, compassion, and respect. They told us the treatment had enabled them to feel safe whilst exploring the issues that had impacted their lives in some cases for decades.

Patients told us staff were always available by phone if they needed them and that they asked about their physical as well as mental health. For example, some patients told us accessing support at the Portman for the psychological wellbeing had given them the confidence to access services for their physical health.

Patients said they felt supported and safe.

Updated 20 January 2021

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.

Updated 16 November 2018

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.

Updated 16 November 2018

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.