stepping stones clinic · stepping stones clinic is registered to provide treatment of disease,...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

StSteppingepping StStonesones ClinicClinicQuality Report

16 Cannon Hill RoadLondon N14 7HDTel: 07864 254 257Website: www.steppingstonesclinic.uk

Date of inspection visit: 13 and 15 August 2019Date of publication: 30/09/2019

1 Stepping Stones Clinic Quality Report 30/09/2019

Overall summary

This was the first time we have inspected and rated thisservice.

We rated Stepping Stones Clinic as good because:

• Young people and their carers were extremely positive,describing staff as ‘superb’, ‘brilliant’ and ‘fantastic’.Staff were described as discreet and of displaying highlevels of empathy. Young people and carers were fullyinvolved in all aspects of their care. A feedback surveyfrom young people and carers was very positive.

• Staff provided a range of treatment and careinterventions for young people based on nationalguidance and best practice. The service haddeveloped its own mobile app for young peoplefocusing on coping skills. The design of the app wasevidence-based, easy to use, and allowed users todownload their own content to personalise it. A rangeof tailor-made, jargon-free, leaflets had also beendeveloped. These provided information and practicaladvice and were written in a way which empathisedwith young people’s, or their carers, experiences.

• Young people and carers were able to becomeinvolved in the management and operation of theservice. This included attendance as a service userrepresentative at the weekly management meetings.

• Leaders had the skills, knowledge and experience toperform their roles, had a good understanding of theservices they managed, and were visible in the serviceand approachable for young people, carers and staff.

• A staff satisfaction survey reported 98% of staff had jobsatisfaction, found the management team accessible,felt involved in decisions and considered theleadership team demonstrated the service values.

• Operational performance and risks in the service weremanaged well.

However:

• Information concerning young people was not alwaysstored in young people’s care and treatment records.This included the details of physical examinations andinvestigations, the reasons for prescribing specificmedicines and detailed risk management plans.Clinical staff may not have had all of the informationrequired to provide safe care and treatment.

• Clinical staff contracted to work in the service had oneprofessional reference before starting work in theservice, rather than two. All other staff checks werecompleted. The service did not have a system in placeto record and monitor when clinicians had receivedsupervision.

• When staff were working alone with clients there wasno system where they could summon urgentassistance.

• Young people and their carers did not have a care planwhich they could easily understand and refer to. Therewere no ‘easy read’ leaflets or leaflets available inlanguages other than English, for young people ortheir carers.

• The complaints policy did not describe howcomplainants’ could appeal if they were dissatisfiedwith the outcome of a complaint investigation or howit was investigated.

Summary of findings


Contents

PageSummary of this inspectionBackground to Stepping Stones Clinic 5

Our inspection team 5

Why we carried out this inspection 5

How we carried out this inspection 5

What people who use the service say 5

The five questions we ask about services and what we found 7

Detailed findings from this inspectionMental Capacity Act and Deprivation of Liberty Safeguards 11

Outstanding practice 20

Areas for improvement 20

Action we have told the provider to take 21

Summary of findings


Stepping Stones Clinic

Services we looked atSpecialist community mental health services for children and young people

SteppingStonesClinic

Good –––


Background to Stepping Stones Clinic

Stepping Stones Clinic provides mental health care andtreatment for children and young people on anout-patient basis. This includes all children and youngpeople up to the age of 25 years. The service providesassessment and treatment by a range of professionals.

The families of young people fund their care andtreatment at the service, or funding is provided byinsurance companies. The service provides care andtreatment for young people in London and from furtherafield including Essex, Kent, Somerset and Hertfordshire.

Stepping Stones Clinic is registered to provide Treatmentof disease, disorder or injury.

There was a registered manager in post at the time of thisinspection.

Stepping Stones Clinic was registered with the CareQuality Commission in July 2018 and we had notinspected this service previously.

Our inspection team

This inspection was undertaken by two CQC inspectorsand a CQC specialist advisor, who was a consultant inchild and adolescent psychiatry.

Why we carried out this inspection

We inspected this service as part of our ongoingcomprehensive mental health inspection programme

How we carried out this inspection

To fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

During the inspection visit, the inspection team:

• visited the service and looked at the quality of theenvironment

• spoke with three young people who were using theservice

• spoke with six carers of young people using the service• spoke with the registered manager• spoke with three other staff members who were all

clinical psychologists

• Looked at 12 care and treatment records of patients:• looked at a range of policies, procedures and other

documents relating to the running of the service

What people who use the service say

Young people and their carers were extremely positive,describing staff as ‘superb’, ‘brilliant’ and ‘fantastic’. Staff

Summaryofthisinspection

Summary of this inspection


were described as discreet and displaying high levels ofempathy towards young people and their carers. Youngpeople and carers reported that staff made a particulareffort to fully understand them and their needs.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated safe as requires improvement because:

• Information concerning young people was not always stored intheir care and treatment records. This included details ofphysical examinations and investigations. This meant clinicalstaff may not have had access to all of the information theyneeded to provide appropriate care and treatment.

• The reason why certain medicines were prescribed for youngpeople was not recorded. This included ‘off label’ medicinesprescribed in a way not covered by the medicines licence. Bestpractice guidance concerning such medicines was notfollowed.

• Clinical staff contracted to work in the service had oneprofessional reference before starting work in the service, ratherthan two. All other staff checks were completed.

• Although young people’s risk management plans werediscussed with young people and their carers, they were notdocumented in detail in young people’s care and treatmentrecords.

However:

• The premises where young people and carers received care wassafe, clean and well furnished.

• Staff assessed and managed risks to young people. Theyresponded promptly to sudden deterioration in a youngperson’s health. Staff worked with patients and their familiesand carers to develop crisis plans.

• Staff understood how to protect young people from abuse andthe service worked well with other agencies to do so. Staff hadtraining on how to recognise and report abuse and they knewhow to apply it.

• Staff regularly reviewed the effects of medicines on each youngperson’s physical and mental health.

• The team had a good track record on safety. The servicemanaged safety incidents well. Staff recognised incidents andreported them appropriately. Managers investigated incidentsand shared lessons learned with the whole team.

Requires improvement –––

Are services effective?We rated effective as good because:

Good –––




• Staff assessed the mental health needs of all young people.They worked with young people and families and carers todevelop individual care and treatment plans.

• The service had developed its own mobile app for youngpeople focusing on coping skills. The design of the app wasevidence-based, easy to use, and allowed users to downloadtheir own content to personalise it.

• Staff provided a range of treatment and care interventions foryoung people based on national guidance and best practice.

• The service included or had access to the full range ofspecialists required to meet the needs of young people undertheir care. Staff had a range of skills needed to provide highquality care. The service supported staff with appraisals andopportunities to update and further develop their skills.

• Staff supported patients to make decisions on their care forthemselves proportionate to their competence. Theyunderstood how the Mental Capacity Act 2005 applied to youngpeople aged 16 and 17 and the principles of Gillick competenceas they applied to people under 16.

However:

• Young people and their carers did not have a care plan whichthey could easily understand and refer to.

Are services caring?We rated caring as good because:

• Young people and their carers were extremely positiveconcerning staff in the service. Staff were described as ‘superb’,‘brilliant’ and ‘fantastic’. Young people and carers reported thatstaff made a particular effort to fully understand them and theirneeds. The quality of these relationships was recognised asvery important by young people, carers and staff.

• A range of leaflets had been made by the service tailored to theneeds of young people, and separately, for their carers. Theseleaflets were jargon-free and provided information andpractical steps to minimise young people’s distress. The leafletswere written in a way which empathised with young people’s,or their carers, experiences.

• Young people and carers were fully informed and involved in allaspects of their care. They were asked for their views whichwere then integrated into young peoples’ care and treatmentplans.

Good –––




• Young people and carers were able to become involved in themanagement and operation of the service. This includedattendance as a service user representative at the weeklymanagement meetings.

• The latest feedback questionnaire from young people andcarers indicated 89% of them were very satisfied with theservice. Ninety four per cent felt that they were understood, allareas they raised were addressed and that they wouldrecommend the service to family or friends.

• Staff had no hesitation in raising any issues concerningdiscrimination towards young people or their carers. They wereconfident their concerns would be taken seriously and did notexpect there to be negative consequences for them for raisingconcerns.

Are services responsive?We rated responsive as good because:

• The service was easy to access. Its referral criteria did notexclude young people who would have benefitted from care.Staff assessed and treated young people who required urgentcare promptly and young people who did not require urgentcare did not wait too long to start treatment. Staff followed upyoung people who missed appointments.

• The service ensured that young people, who would benefitfrom care from another agency or professional, made a smoothtransition.

• The service had a complaints policy and staff knew how tohandle complaints. There had been no complaints about theservice in the previous year.

However:

• The complaints policy did not describe how complainantscould appeal if they were dissatisfied with the outcome of acomplaint investigation or how it was investigated.

• Although the service had undertaken a ‘green light toolkit’audit, information for young people and carers was notavailable in an ‘easy read’ version. Information was notavailable in languages other than English.

Good –––

Are services well-led?We rated well led as good because:

Good –––




• Leaders had the skills, knowledge and experience to performtheir roles, had a good understanding of the services theymanaged, and were visible in the service and approachable foryoung people, carers and staff.

• Staff knew and understood the provider’s vision and values andhow they were applied in the work of their team.

• Staff felt respected, supported and valued. They felt able toraise concerns without fear of retribution.

• Our findings from the other key questions demonstrated thatgovernance processes operated effectively and thatperformance and risk were managed well.

• A staff satisfaction survey reported 98% of staff had jobsatisfaction, found the management team accessible, feltinvolved in decisions and considered the leadership teamdemonstrated the service values.

• The service had developed a bespoke mobile app for youngpeople and were planning to apply for network accreditationfrom the Royal College of Psychiatrists.

However:

• The service did not have a system in place to record andmonitor when clinicians had received supervision.




Mental Capacity Act and Deprivation of Liberty Safeguards

• All staff had received training in the MCA. Theyunderstood the legal framework concerning capacity,both under the MCA and Gillick competency, for youngpeople aged 16 years or over. The service had a mentalcapacity policy.

• Staff in the service assumed a young person had thecapacity to make decisions regarding their treatment.Where young people were not Gillick competent andtheir carers made decisions regarding treatment, thiswas not always formally recorded.

• The service had an Independent Mental CapacityAdvocate (IMCA) who could support young people over18 years of age who did not have the capacity to makecertain decisions regarding their treatment.

Detailed findings from this inspection


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Are specialist community mental healthservices for children and young peoplesafe?

Requires improvement –––

Safe and clean environment

The service operated from a clinic providing dentistry andchiropody. Two consulting rooms were used by the service.The service did not manage the building. Nevertheless,staff in the service monitored the cleanliness and healthand safety of the premises. Staff undertook audits forcleanliness, infection control, fire safety and maintenance.Fire equipment was maintained and portable electricalappliances were tested. There were infection control andhand hygiene policies.

The consulting rooms in the service did not have alarms. Arisk assessment for the service assessed the risk of violenceand aggression as low. There had been no incidents ofviolence and aggression in the previous year. However,there was a risk that staff alone in a consultation roomwould be unable to call for help if needed.

All areas of the service were clean with comfortablefurnishings. The building was well maintained with brightdécor and a small outside area with seating.

The service did not have a clinic room. However, there wasan automated external defibrillator in the service. This isused to restart a person’s heart, if required. Staff also useda portable electronic sphygmomanometer (blood pressuremachine). Both items of equipment were calibrated toensure they worked effectively. Oxygen on the premiseshad also been tested.

Safe staffing

The service was open on the telephone Monday to Fridayfrom 8am to 8pm. Staff were not always based in theservice during those times, but were in the service everyday.

A consultant psychiatrist was the registered manager andwas assisted by an office manager and secretary. Otherclinicians working in the service were independentcontractors and worked as required. The service checkedthat all clinicians had current professional registration,appropriate clinical experience and academicqualifications, professional indemnity insurance, and adisclosure and barring service (police) certificate. However,the service received only one professional reference, ratherthan two, for clinicians. The consultant psychiatrist had,however, handpicked the clinicians contracted to work withthe service.

The consultant psychiatrist in the service was on-callthroughout the day and night. Young people or carers hadthe telephone number of the consultant. During periods ofabsence or sickness, arrangements were in place foranother consultant psychiatrist to provide input into theservice.

The provider required all staff to undertake 11 types oftraining. These included fire safety, health and safety,infection control and information governance. All staff hadundertaken these types of training. However, the provider’straining matrix recorded that four staff had undertakenbasic life support training and this was valid for two orthree years. Two staff members had undertaken thistraining in 2017. Guidance from the UK Resuscitation

Specialistcommunitymentalhealthservicesforchildrenandyoungpeople

Specialist community mentalhealth services for children andyoung people

Good –––


Council is that life support training should be undertakenevery year. The registered manager was aware that thistraining should be undertaken annually. They had plannedto address this.

Assessing and managing risk to patients and staff

When young people first attended the service, staffundertook a risk assessment of the young person. Thisconsisted of past and current episodes of risk behaviourinvolving the young person. Risk assessments wereupdated after any incidents.

Young people’s risk management plans were based on theirassessed risks. This could involve a parent sleeping in thesame room as their child at home for a period of time. Thiswas to reduce the risk of the young person self harming.However, details of how young people’s risks would bemanaged and reduced were not always documented indetail. There was not always a record of how high risksituations would be identified and minimised in youngpeople’s risk management plans. When young people hadthoughts of suicide and self harm, they or their carers weregiven a specific leaflet. This described how young peoplecould develop coping strategies to deal with thosethoughts. Young people’s incidents of risk behaviour werediscussed amongst the staff team and documented in themonthly risk report for the service.

Young people and their carers had crisis plans. These were,however, general. They consisted of having the consultant’snumber to contact if required. For young people withthoughts of self harm and suicide, carers were providedwith a crisis plan leaflet. This included possible triggers forself harm and a practical, structured approach to dealingwith young people's emotional crisis. Young people werealso directed to the mobile app designed by the service.This app was specifically for young people with thoughts ofself harm or suicide. It included distraction techniques, andemotional and biological moderation techniques. The appclearly signposted young people to the most appropriatetechniques when they were experiencing a crisis. If thematter was very urgent young people and carers were toattend an emergency department.

The service had a lone working policy for when staff wereworking alone in the service. However, the service had notimplemented appropriate safety protocols for staff tosummon assistance from other people in the building.

Staff were trained at level three in safeguarding children.This is the standard required for staff in child andadolescent services. Staff had a good understanding ofsafeguarding and the service maintained a safeguardingregister. Staff in the service had made four safeguardingreferrals to the local authority in 2019. These involvedyoung people harming themselves or being at risk of harmfrom others.

Young people’s care and treatment records were stored ona ‘cloud’ system. This meant they were accessible toinvolved clinicians at any time. Clinicians notes of sessionsdid not always describe the interventions used. This meantclinicians did not always have access to the informationthey may need.

Staff in the service did not administer or store medicines.The consultant psychiatrist was the only clinician whoprescribed medicines to young people. Young people’scarers would supervise young people’s medicines includingtheir safe storage. Young people were provided with a chartspecific to their prescribed medicine. This was to record,every day, any side effects from their medicine. This wasbest practice. Young people and their carers were alsoprovided with leaflets, developed by the service,concerning medicines they were prescribed. Theconsultant also had a telephone appointment with theyoung person or their carers one week after prescribingmedicine. This was to check on any unwanted side effects.Young people’s GPs were informed when medicines werestarted or changed.

The consultant did not always record the reasons for thechoice of medicines they were prescribing to young people.They did not record that young people or their carers wereinformed of the risks and benefits, or reasons, whenunlicensed medicines were being prescribed, asrecommended in best practice guidance (Good practice inprescribing and managing medicines and devices, GeneralMedical Council,2013).

Young people had their blood pressure and weightrecorded before medicines were prescribed. The servicecommunicated with young people’s GPs for other physicalhealth assessments or investigations. The consultant saidthat she actively tracked and monitored physical healthassessments and investigations required for young people.An audit of this was also undertaken. However, theoutcome of these assessments or investigations were notalways clearly recorded in young people’s care and



Good –––


treatment records. For example, young people prescribedantipsychotic medicines should have anelectrocardiogram. Young people prescribed medicines forattention deficit hyperactivity disorder should have anyheart risks assessed and reviewed. There was no record ofthese assessments or investigations.

Track record on safety

There had been no serious incidents in the service in theyear before the inspection.

Reporting incidents and learning from when things gowrong

All staff knew what incidents to report and how to reportthem. Young people’s incidents of risk behaviour werediscussed amongst the staff team and documented in themonthly risk report for the service. The service had anincident policy.

Incidents were reported within 24 hours of staff becomingaware of it. An incident investigation was then undertakenwithin two weeks. All staff received an email concerning theincident and the outcome of the investigation. Thisincluded learning points from the incident. Staff told usabout lessons learnt from an incident involving a youngperson. This learning had re-emphaised the importance ofconsidering substance misuse when staff assessed youngpeople’s risks.

Duty of candour is a legal requirement, which meansproviders must be open and transparent with clients abouttheir care and treatment. This includes a duty to be honestwith clients when something goes wrong. Staff in theservice knew and understood the duty of candour and itsrequirements.

Are specialist community mental healthservices for children and young peopleeffective?(for example, treatment is effective)

Good –––

Assessment of needs and planning of care

Young people had a comprehensive assessment when theyfirst attended the service. This included information from

their carers together with an interview with the youngperson alone. If a young person was thought to haveattention deficit hyperactivity disorder or attention deficitdisorder, information was obtained from many sources,such as the young person’s school. The young person’sassessment incorporated their family, social, educationaland medical history. Young people’s blood pressure andweight were recorded. Other referral information, such asinformation concerning young people’s physical health wasnot available, in detail, in their care and treatment records.When young people had previously been assessed ashaving autism or attention deficit hyperactivity disorder,there was no record in their care and treatment records ofwho, how and when they had been given this diagnosis.

Young people’s plan of care and treatment was discussedwith them and their carers. However, there was no writtencare plan for young people and carers to refer to. Theconsultant said that the letter sent to young people’s GPwas their care plan. However, these letters were written inlanguage for other professionals rather than young peopleor their carers.

Best practice in treatment and care

For young people prescribed antidepressant medicines,best practice guidance from the National Institute forHealth and Care Excellence was not always followed. TheNational Institute for Health and Care Excellencerecommend fluoxetine is initially prescribed for children oryoung people due to evidence that the benefits of thatmedicine outweigh any risks (Depression in children andyoung people: identification and management, 2019). Theconsultant prescribed other antidepressants in the samegroup of medicines. They also closely monitored the sideeffects of these medicines. However, for young people whodid not respond to any other antidepressants, theconsultant prescribed venlafaxine. National Institute forHealth and Care Excellence guidance specifically statesthat venlafaxine should not be used for the treatment ofdepression in children or young people (Depression inchildren and young people: identification andmanagement, 2019). The summary product characteristicsfor venlafaxine state that if used in this way there must becareful monitoring for side effects. This was undertaken bythe consultant. When a young person experienced a lack ofsleep due to their depression, the consultant prescribedthe medicine mirtazapine. This was a prescription outsideof the licence for mirtazapine.



Good –––


Young people with attention deficit disorder or attentiondeficit hyperactivity disorder were prescribed specificmedicines following best practice guidance (Attentiondeficit hyperactivity disorder: diagnosis and management,National Institute for Health and Care Excellence, 2018).

A range of psychological therapies were available for youngpeople. These included cognitive behavioural therapy,group dialectical behaviour therapy, mentalisation-basedtherapy and different types of family therapy. The type oftherapy most appropriate for the young person was basedon a comprehensive assessment and best practiceguidance from the National Institute for Health and CareExcellence. An example of this was that young peoplereceiving antidepressant would also have 12 weeks ofcognitive behaviour therapy ( Depression in children andyoung people: identification and management, 2019).

Young people who had thoughts of suicide and self harmwere directed to a mobile app of coping skills designed bystaff in the service. This meant young people could haveways of reducing their distress all of the time. The app usedrecognised techniques to minimise young people’s distress.It contained features such as mindfulness and guidedmeditation, guidance to help reduce temperature andpulse rate, using exercise as a coping mechanism, andguidance on using touch therapeutically. Young peoplecould also upload calming and pleasant photos and music.The language used in the app could be understood by arange of age groups and clearly identified differentstrategies for young people to use at different times. Forexample, the ‘rescue me – life jacket’ section was for whenyoung people felt overwhelmed and at risk of self harm.

Other therapists were available to meet the specific needsof individual young people. A dietitian was available,particularly for young people with an eating disorder. Anoccupational therapist worked with some young people,such as supporting them in public places to reduce theiranxiety.

The service used the revised children’s and anxietydepression scale (RCADS) and the Vanderbilt ADHDdiagnostic rating scale (VADRS) as clinical outcomemeasures for young people.

A number of clinical audits were carried out in the service.These included a monthly audit of young people’s care andtreatment records and physical health monitoring of youngpeople. A medicines management audit was also

undertaken, as well as an audit to review if young people’streatment was delivered in accordance with NationalInstitute for Health and Care Excellence best practiceguidance. This audit identified all young people werereceiving treatment in accordance with National Institutefor Health and Care Excellence guidance. As the rationalefor prescribing specific medicines was not alwaysdocumented, it was not possible to confirm this.

Skilled staff to deliver care

The service had access to staff who could provide the fullspectrum of care and treatment approaches required bypatients. These included clinical psychologists,psychotherapists, occupational therapists, a familytherapist and a dietitian.

The clinicians working in the service had extensiveexperience of providing care and treatment for childrenand young people. They had the required qualificationsand had undertaken additional postgraduate educationand training. This meant that staff had particular areas ofspecialisation and could meet the varied needs of theyoung people who used the service. These included staffwith specialist knowledge and experience in autism, selfharm, attention deficit hyperactivity disorder, eatingdisorders and various treatment approaches.

The consultant psychiatrist had regular peer supervision.Staff contracted to work in the service had their ownsupervision arrangements. However, the provider did nothave details of these to ensure that all clinical staff hadregular supervision. Discussions had taken place for clinicalpsychologists working in the service to start their own peersupervision group. At the time of the inspection, this hadnot commenced.

There were team meetings every three months. These werevirtual internet meetings and discussed operationalmatters such as audits, risks and quality. Any emergingissues which could not wait for the next team meeting wereemailed to all clinicians by the service manager.

All staff had received an annual appraisal concerning theirwork in the service. This appraisal reviewed their work overthe previous year. It also identified the staff members’learning needs and how they would aim to achieve them.

Multi-disciplinary and inter-agency team work

Multi-disciplinary meetings were scheduled to take placeevery two months. This was a forum to discuss young



Good –––


people with complex needs. However, clinicians alsocontacted each other in between these times to discussparticular clients and to handover information. Thisincluded contact by email and telephone.

The service worked well with other agencies andprofessionals. For example, therapists closer to youngpeople’s homes were often contacted to provide a service.Contact with the service was then maintained toco-ordinate the young person’s treatment. The service alsohad contact with NHS services when required and provideddetailed information concerning young people to them.Letters to young people’s GPs were sent regularly to informthem of treatment. However, information from otheragencies or professionals was not consistently uploaded toyoung peoples’ care and treatment records.

Good practice in applying the MCA

All staff had received training in the MCA. They understoodthe legal framework concerning capacity, both under theMCA and Gillick competency, for young people aged 16years or over. The service had a mental capacity policy.

Staff in the service assumed a young person had thecapacity to make decision regarding their treatment. Whereyoung people were not Gillick competent and their carersmade decisions regarding treatment, this was not alwaysformally recorded.

The service had an Independent Mental Capacity Advocate(IMCA) who could support young people over 18 years ofage who did not have the capacity to make certaindecisions regarding their treatment.

Are specialist community mental healthservices for children and young peoplecaring?

Good –––

Kindness, dignity, respect and support

Young people and their carers were extremely positiveconcerning staff in the service. They used the words‘superb’, ‘brilliant’ and ‘fantastic’. Young people describedthe consultant psychiatrist as ‘naturally kind and caring’and they felt safe talking to her.

Staff were described as discreet and displaying high levelsof empathy towards young people and their carers. Youngpeople and carers reported that staff made a particulareffort to fully understand them and their needs. The qualityof these relationships was recognised as very important byyoung people, carers and staff.

Young people and their carers were provided withinformation to understand and manage their mental healthproblems. A range of leaflets had been made by the servicetailored to the needs of young people, and separately, fortheir carers. These leaflets were jargon-free and providedinformation and practical steps to minimise young people’sdistress. The leaflets were written in a way whichempathised with young people’s, or their carers,experiences. Young people with suicidal thoughts or whoself harmed could use the specially designed app to helpthem manage their feelings.

Young people and their carers were supported to accessother services when this was convenient for them ornecessary. If young people travelled a long distance to theservice, the service located specialists nearer to their hometo provide treatment. The service had referred youngpeople to child and adolescent community services andcrisis teams when necessary. If there was an urgent crisis,young people and their carers were advised to attend anemergency department. They were also advised to give theconsultant psychiatrist’s telephone details to staff in theemergency department. This meant that emergencydepartment staff could contact the consultant for detailedinformation about the young person. Staff also referredyoung people and carers to support groups and otherorganisations locally to them.

Young people’s assessment for the service wascomprehensive, and included the young person’s personal,cultural, religious and social needs. These were thenincorporated into the young person’s care and treatment.

Staff had no hesitation in raising any issues concerningdiscrimination towards young people or their carers. Theywere confident their concerns would be taken seriouslyand did not expect there to be negative consequences forthem for raising concerns.

Staff were careful to maintain the confidentiality of youngpeople and their parents. At their first appointment, theconsultant psychiatrist saw the young person and their



Good –––


parents or carers separately, and then together. Twosiblings had been treated at the service. The clinicalpsychologist for one of the siblings did not access the carerecords of the other as they did not have consent to do so.

The involvement of people in the care they receive

Young people and carers were fully informed and involvedin all aspects of their care. They were asked for their viewswhich were then integrated into young peoples’ care andtreatment plans.

Young people and carers were able to become involved inthe management and operation of the service. Thisincluded attendance as a service user representative at theweekly management meetings.

Young people and their carers were able to providefeedback about the service in a number of ways. There wasa group for young people to provide feedback about theservice. After their first appointment, a feedbackquestionnaire was sent to young people and their carers byemail. The response to this questionnaire was anonymouswhen it was received by the service. The latest feedbackfrom young people and carers indicated 89% of them werevery satisfied with the service. Ninety four per cent felt thatthey were understood, all areas they raised were addressedand that they would recommend the service to family orfriends.

A group for carers had been planned. Due to unforeseencircumstances it had been delayed but was due to startlater in 2019.

Are specialist community mental healthservices for children and young peopleresponsive to people’s needs?(for example, to feedback?)

Good –––

Access and discharge

Young people were seen within a target time of four weeksfrom referral. In practice, young people were usuallyassessed within two to three weeks of referral. Wheninformation indicated an assessment was required moreurgently, the consultant psychiatrist assessed the clientwithin 24 hours.

When young people or carers contacted the service theyreceived a prompt response. If the consultant wasunavailable, the office manager or secretary would take thecall. In some cases, they interrupted the consultant’s otherwork when the matter was urgent. Carers reported that theconsultant was very accessible and that they had found theservice responsive to their needs.

When young people or carers stopped using the service inan unplanned way staff in the service attempted to contactthem. This continued until staff in the service could speakto the young person or carers and establish that they werealright.

There was some flexibility in appointment times, withevening appointments available for children and youngpeople. On some occasions, appointments were lessflexible and this was due to the specialist skills of a specificclinician and when they could attend the service.Appointments were not cancelled, only occasionallyrearranged, and ran on time.

Young people and carers were supported by staff duringtransfers of care. This included when young peoplerequired inpatient mental health care. The consultant hadaccess to such beds. If a young person attended anemergency department the consultant was available toprovide a detailed handover to staff at the hospital. Asimilar handover was provided when young people weretransferred to a crisis team, community child andadolescent mental health service or other therapists.

The facilities promote recovery, comfort, dignity andconfidentiality

The consultation rooms in the service had adequatesoundproofing to maintain confidentiality during meetingswith young people and carers.

Young people were supported to engage with thecommunity and maintain relationships when their mentalhealth problems affected this. An example was of theoccupational therapist having a programme of communityactivities for a young person. This was to assist them inovercoming anxiety.

Meeting the needs of all people who use the service

The service made adjustments for young people and theircarers when necessary. For example, a young person whowas a wheelchair user was seen in a ground floor office.Other young people were seen in first floor consultation



Good –––


rooms. Some young people and their family members andcarers did not speak English. A clinical psychologistworking with the service provided interpretation. Theservice would book interpreters if required.

Young people and carers were provided with informationconcerning their specific needs. This included verbal andwritten information concerning treatment and otherservices appropriate for their needs. Young people andcarers were advised of how they could make a complaintabout the service.

The service had undertaken a green light toolkit auditbefore the inspection. The green light toolkit is arecognised audit to assess how user-friendly mental healthservices are for people who have a learning disability orautism. The audit had highlighted that no easy readinformation and leaflets were available in the service. Theservice was in the process of developing specific leaflets.

Staff in the service supported young people and theircarers to attend activities specific to their protectedcharacteristics. Staff supported young people from a black,minority ethnic background and young people whoidentified as LGBT+.

The service had not produced leaflets in differentlanguages. One young person and their carers, in theprevious year, had not spoken English as a first language. Aclinician in the service interpreted. Interpreters wereavailable when staff could not speak English well.

Listening to and learning from concerns andcomplaints

The service had received no complaints in the year beforethe inspection. Young people and carers were aware of howthey could complain about the service if they wished to.

The service had a complaints policy. Overall, this followedbest practice guidance. However, the complaints policy didnot describe how complainants could appeal against theoutcome or of how the complaint was investigated. Staffwere aware of how to handle complaints and concerns.

Are specialist community mental healthservices for children and young peoplewell-led?

Good –––

Vision and values

The vision of the service was to provide safe, high qualityand effective care and treatment to young people whenthey needed it. This meant there were limited waiting timesand young people and their families could accesstreatment and support for all of their needs at the sametime.

Staff and clinicians working in the service were enthusiasticin embracing the vision of the service. This had been clearlycommunicated to them and they reflected the vision in theway that they worked.

Many young people’s care and treatment was funded byhealth insurance companies. Some young people requiredtreatment beyond that agreed with the insurancecompany. Any barriers to funding additional treatmentwere overcome without delay to ensure young people’streatment could continue.

Good governance

There was a clear framework of policies, procedures andpractices which ensured that the leadership were sightedon safety and quality issues in the service. The system ofaudits, performance reports, and governance meetingsensured that incidents, safeguarding referrals andcomplaints were reviewed and discussed regularly. Therewas a specific focus on ensuring the virtual team ofclinicians were provided with up to date information sothat they could learn from incidents and were aware ofchanges to the provider’s systems. However, there was norecord that the provider had oversight of cliniciansreceiving regular supervision.

The service had a risk register, which reflected risks to theservice. A business continuity plan was in place whichidentified how the service would continue to operate incase of unplanned disruption.

There were policies available to staff via the ‘cloud’ andstaff were informed when new policies and procedureswere introduced. The service had a ‘being open’ andwhistleblowing policy. Staff were confident in raisingconcerns to the leadership team without fear of anyconsequences.



Good –––


Leadership, morale and staff engagement

The leadership team in the service were experienced,skilled and capable to ensure the service was operated in away that provided high quality care. They were accessibleto young people, carers and staff.

A staff satisfaction survey was undertaken in June 2019.Ten staff (59%) completed the survey. Job satisfaction,accessibility of the management team, involvement indecisions and demonstrating values all received a score of98%. Staff felt connected to, and engaged with, the serviceleadership and were complimentary regarding the systemsdeveloped to communicate with a virtual team.

Commitment to quality improvement and innovation

The service had developed its own mobile app for youngpeople focusing on coping skills. The design of the app wasevidence-based, easy to use, and allowed users todownload their own content to personalise it.

The service was in the process of seeking accreditation ofthe Quality network for Community CAMHs from the RoyalCollege of Psychiatrists’ College Centre for QualityImprovement (CCQI).



Good –––


Outstanding practice

The service had developed its own mobile app for youngpeople focusing on coping skills. The design of the appwas evidence-based, easy to use, and allowed users todownload their own content to personalise it.

Areas for improvement

Action the provider MUST take to improve

• The service must ensure that all informationconcerning young people is stored in their care andtreatment records. This must include results ofphysical examinations and investigations, therationale for prescribing medicines and detailed riskmanagement plans for young people. Regulation17(2)(c)

• The provider must ensure that there is a system whichstaff who are lone working can use to summon urgentassistance. Regulation 17(2)(b)

• The provider must ensure that two professionalreferences are obtained for clinicians contracted towork in the service. Regulation 19(3)(a)

Action the provider SHOULD take to improve

• The provider should ensure a system is in place whichrecords when clinicians have received supervision.

• The provider should ensure that young people andtheir carers have a care plan which is easilyunderstood and describes what treatment is beingprovided and how.

• The provider should ensure the complaints policydescribes the information that should be given tocomplainants to appeal the outcome of a complaint orhow a complaint has been investigated.

• The provider should ensure that information for youngpeople and their carers is easily accessible, includingeasy read versions and versions in different languages.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Treatment of disease, disorder or injury Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulated activity

Treatment of disease, disorder or injury Regulation 19 HSCA (RA) Regulations 2014 Fit and properpersons employed

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


stepping stones clinic · stepping stones clinic is registered to provide treatment of disease,...

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