anna freud centre newapproachcomprehensive report ... ·...

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.

TheThe AnnaAnna FFrreudeud CentrCentreeQuality Report

The Anna Freud Centre12 Maresfield GardensLondonNW3 5SUTel: 02077942313Website: www.annafreud.org

Date of inspection visit: 10 May 2016Date of publication: 01/08/2016

1 The Anna Freud Centre Quality Report 01/08/2016

Overall summary

We rated the service as good because:

• The service managed caseloads well so that youngpeople were seen quickly. There was no waiting listto access the majority of specialist teams. Wherethere were waiting lists, they were between one andsix weeks.

• The service’s safeguarding procedures were robust.Staff compliance with safeguarding training washigh.

• Staff were aware of how to report an incident andthere was evidence of change being made within theservice as a result of feedback from incidents.

• Staff responded to complaints appropriately and in atimely way.

• The centre offered a range of psychological therapiesand research at the centre had directly contributedto NICE guidance. The centre had been involved inusing several new models of intervention that werethen rolled out nationally.

• Young people and carers said the service was helpfuland described the service as brilliant. Staff wereavailable to speak to carers when they wanted andreturned calls when necessary. The service had awelcoming waiting room and plenty of therapyrooms.

• The centre had good working links with externalorganisations.

• The centre website was up to date, young personfriendly and informative. The centre was involved inseveral web-based support services for youngpeople that were developed by young people.

• Staff received regular supervision and felt supportedand proud to work at the centre. Staff said the centrehad

However:

• The centre had introduced electronic records inJanuary 2016 and thorough recording was not yetembedded across the staff team. We found staff didnot regularly record when they reviewed risk andwhat the individual plans for care were.

• There was no central recording of some health andsafety audits and actions. For example there was noevidence that staff regularly wiped down toys andresources after use to reduce risk of spread ofinfection. Also, staff assessed the environment forligature risks in 2015, however had not kept a writtenrecord of this. There was no written audit plan forwhen this would next take place.

• The centre did not have written information aboutsources of support in a crisis. Where otherinformation leaflets were available, for example onhow to make a complaint, these did not outlinewhether they were available in other languages or indifferent formats, for example in an easy read formator braille.

• In the 12 months leading up to the inspection, theservice had not notified the CQC of all reportableincidents in line with statutory requirements.

• The systems and processes around employmentrecords had not highlighted that two staff recordsdid not contain up-to-date disclosure and barringservice (DBS) checks.

Summary of findings


Contents

PageSummary of this inspectionOur inspection team 5

Why we carried out this inspection 5

How we carried out this inspection 5

Information about The Anna Freud Centre 5

What people who use the service say 6

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

Detailed findings from this inspectionMental Health Act responsibilities 11

Mental Capacity Act and Deprivation of Liberty Safeguards 11

Outstanding practice 23

Areas for improvement 23

Action we have told the provider to take 24

Summary of findings


The Anna Freud Centre

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

TheAnnaFreudCentre

Good –––


Our inspection team

Inspection Lead: Natalie Austin Parsons, Inspector, CareQuality Commission

The team was comprised of one CQC inspector, one CQCinspection assistant, one expert by experience and onespecialist advisor with experience of working in child andadolescent mental health services.

Why we carried out this inspection

We inspected this core 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?

Before the inspection visit, we reviewed information thatwe held about these services, asked a range of otherorganisations for information and sought feedback frompatients at three focus groups.

During the inspection visit, the inspection team:

• visited the service where treatment was provided,looked at the quality of the environment andobserved how staff cared for patients

• spoke with 10 young people and parents or carerswho were using the service

• interviewed the clinical director and the medicaldirector for the service

• interviewed 10 other staff members including clinicalpsychologists, systemic family therapists, heads ofservice, the operations manager and administrativestaff

• spoke with three staff members from schools wherethe service provided assessment and treatment

• attended and observed a parent’s panel meeting

• looked at six care and treatment records of patients

• looked at eight staff employment records

• looked at a range of policies, procedures and otherdocuments relating to the running of the service

Information about The Anna Freud Centre

The Anna Freud Centre is a children’s mental healthcharity providing support and treatment to children,young people and families. The centre provided thesecare services alongside academic research and trainingfor mental health professionals. Staff in specialist subteams provided two types of service called helping

families services and trauma and maltreatment services.The trauma and maltreatment service worked closelywith social services and court services and supportedfamilies involved in court proceedings.

Summaryofthisinspection

Summary of this inspection


The whole organisation had grown in size over theprevious two years and was part-way through arelocation to a new integrated site at Kings Cross. Thetarget date for finalising the move was September 2018.

The Anna Freud Centre was last inspected in January2014 and met the five essential standards of quality and

safety being inspected. The service is registered toprovide the regulated activity of treatment of disease,disorder or injury. There was a registered manager inplace at the time of inspection.

What people who use the service say

Young people and parents/carers were very positiveabout the service they had received and the staff at thecentre. Parents/carers said their children responded wellto staff and that staff offered family support whenneeded.

Young people and parents/carers said staff wereempathetic, kind and informative. They said staff were

always available to speak to on the telephone and wouldalways call them back if they left a message. Youngpeople and parents/carers particularly mentionedreception staff for their warm and welcoming approach.

People said they felt listened to. They said they had seenthe changes in themselves or their children as a result ofthe support and treatment they received.




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 required improvement because:

• Risks were not always followed through to care plans to outlinehow staff were ensuring the risks were being managed. Therewas no evidence of when staff reviewed risks for each youngperson.

• Mandatory training did not include training in a number orareas that could ensure patient safety. This included training oninfection control, fire safety and basic first aid.

• There was no evidence that staff regularly cleaned toys. Thiswas an infection control risk.

• In the 12 months leading up to the inspection, the service hadnot notified the CQC of all reportable incidents in line withstatutory requirements.

• There were no up-to-date disclosure and barring service(criminal records) checks for two members of staff.

• Staff did not routinely provide written information about howto access alternative services out-of-hours and in anemergency. The service relied on an informal process to contactservice staff to then be redirected if necessary.

However:

• The service managed caseloads well so young people wereseen quickly. When staff received a referral they contactedfamilies on the phone to discuss the reason for referral andcould establish risk quickly.

• Safeguarding procedures for the service were robust and ratesof staff safeguarding training were high.

• Staff knew how to report an incident. There was evidence ofchange being made within the service as a result of feedbackfrom incidents.

• The service kept three risk event registers coveringsafeguarding, complaints and serious incidents. These wereregularly reviewed and acted upon.

• All areas were visibly clean and well maintained.

Requires improvement –––

Are services effective?We rated effective as good because:

Good –––




• The centre offered a range of psychological therapies andresearch at the centre had directly contributed to NICEguidance. The centre provided specialist training toprofessionals, for example it had trained over 5,000practitioners in mentalization based treatment.

• Staff used outcome measures and evaluated service deliveryregularly. The CAMHS Outcomes Research Consortium (CORC)was based at the centre. This is a learning collaboration withover 70 CAMHS members that uses routine outcome measuresto improve services.

• In partnership with another service provider the centredeveloped and implemented a model of care called THRIVE.based on identifying a young person’s needs rather thanfocussing on their diagnosis or the severity of the illness.

• Young people and parents/carers said they found the servicehelpful.

• Staff received regular supervision and recorded casesupervision in individual case notes. Staff had opportunities toattend specialist training run by the centre.

• The centre had good working links with external organisations,for example schools. The centre developed a network forschools and teachers called Schools in Mind. This helpedteachers to identify mental health problems in young peopleand appropriate support.

However:

• We did not find comprehensive written information about theplan for care or evidence that staff regularly reviewed the planfor care. Although young people and parents/carers felt theywere aware of the plan as staff shared this information verbally.

Are services caring?We rated caring as good because:

• Young people and parents/carers gave very positive about staffand said they were kind, caring and extremely supportive.Young people said all staff were friendly and had made themfeel welcome.

• Most parents/carers and young people said staff explainedconfidentiality from the first time they met and understoodwhat this meant.

• Parents/carers and young people said they had discussed atreatment plan with staff. They could contact staff about this ifthey had questions.

• Young people and parents/carers were able to give feedbackabout the centre and the care they received.

However:

Good –––




• Most young people and parents/carers did not have a writtencopy of their care plan.

Are services responsive?We rated responsive as good because:

• There was no waiting list to access most services. The specialistteams with waiting lists had them for between one and sixweeks.

• Parents/carers said staff were available by telephone to speakwith outside of appointment times.

• The service had a welcoming waiting room and plenty oftherapy rooms. There was a baby changing room on the samefloor as therapy rooms used for baby psychotherapy.

• The centre had a website that was young person friendly andinformative. The centre was also involved in several web-basedsupport services for young people.

• The service was accessible to people requiring disabled accessand the website was designed to be compliant with guidelinesto ensure it could be accessed by partially blind people. Staffaccessed interpreter services when needed.

• The service managed complaints well. Staff could describe howto manage a complaint and staff responded to complaints all ina timely way and within the target time of 15 days.

However:

• Not all information leaflets included information about whetherthey were available in other languages or in different formats,for example in an easy read format or braille.

Good –––

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

• Staff said they felt proud to work at the centre and that therewas good leadership. Staff felt the recent change to make twomain service lines had made a positive impact on the centre.Morale was good and staff had opportunities to providefeedback and input into service development.

• There were clear lines of reporting and responsibility forincidents, complaints and safeguarding issues

• There were very low rates of sickness and absence across thecentre. Staff were aware of the whistleblowing policy and feltable to voice concerns without fear of victimisation.

However:

Good –––




• Governance processes did not cover all the necessaryoperational areas of the service. For example recruitmentchecks, mandatory training and thorough completion ofelectronic patient records.




Mental Health Act responsibilities

We do not rate responsibilities under the Mental HealthAct 1983 (MHA). We use our findings as a determiner inreaching an overall judgement about the Provider.

Staff did not receive specific training in the MHA and theMHA Code of Practice. The service did not work withpeople who were subject to detention under the MHA. Inthe event that a MHA assessment was required, thiswould be requested externally.

Mental Capacity Act and Deprivation of Liberty Safeguards

Staff did not receive specific training in the MCA or theMCA Code of Practice. From the end of 2015, the centreintroduced information on the MCA to level twosafeguarding training which all staff had received.

The centre had a service user consent policy whichoutlined capacity, incapacity as well as competence. Thispolicy outlined a clear summary of the MCA and how itwas relevant to the service.

Staff had a clear understanding of Gillick competenceand consideration of this in practice.

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

• Therapy rooms were not fitted with alarms. Staffassessed potential risks before an appointment andused a therapy room near to reception if needed. Thiswas so they could get assistance quickly, if required.Staff would also advise colleagues of the appointment.An incident of staff raising an alarm had not taken placein the 12 months leading up to the inspection.

• All areas were visibly clean and well maintained. Theservice had a large rear garden that was wellmaintained. This could be accessed through meetingrooms on the lower ground floor. A local school used aspace in the garden for a school project. The centreused an external cleaning company. Cleaning recordsshowed the cleaning jobs done in each room and howoften took place.

• Staff said they regularly disinfected toys and gamesused in therapy after each use to reduce the risk of thespread of infection. However there were no records toevidence this. Not all therapy rooms contained wipes tocarry this out.

• There were systems in place to monitor buildingmaintenance. A noticeboard in the waiting roomoutlined the fire evacuation routes.

• Staff said they had assessed the environment forligature risks in 2015, however had not kept a writtenrecord of this. Patients used two toilets where a numberof ligatures had been removed. The premises securitypolicy stated that children and young people must beaccompanied by staff at all times, apart from whenusing the toilet.

Safe staffing

• Specialist team caseloads and staff number varied insize. The centre monitored caseloads and length of stayto make sure they were manageable.

• In the 12 months before the inspection, vacancy rateswere low at 1-2%. Bank and agency staff were not usedfor clinical positions. The sickness rate was also low at1-2%.

• Staff were required to undertake four types ofmandatory training. These were safeguarding childrenlevels one, two and three and information governance.Compliance with training in information governancewas 80% and training in child protection levels one, twoand three was over 97%. The level two safeguardingtraining included training on the MCA and this was notdelivered as separate training. Staff were not required toundertake mandatory training in fire safety, first aid,infection control or introduction to the Children Act.Without this training staff did not know essentialinformation in order to keep families and staff safe in theservice.

Assessing and managing risk to patients and staff

• Staff assessed the potential risks to young people whenthey started accessing the service. Each specialist teamused a specific tool to assess risks. In six care records,

Specialistcommunitymentalhealthservicesforchildrenandyoungpeople

Specialist community mentalhealth services for children andyoung people

Good –––


five contained a risk assessment. One young person didnot have a risk assessment. In the complex cases courtservice, risks for the young person were high in everycase. The service then worked jointly with socialservices to minimise risks.

• The care records looked at were from six differentsub-teams. Across these records, there was no evidencethat staff regularly reviewed and updated riskassessments. One risk assessment had been completedfive years earlier. Staff said they assessed risk moreregularly for those young people with increased risks,however there was no record of this. There was norecord that young people assessed as having lowerlevels of risk were reassessed. Reassessment may haveidentified if the young person’s risks had increased. Riskassessments did not contain an explanation of why staffclassified risks as low, medium or high.

• Risk assessments did not always lead to young peoplehaving risk management plans. Young people’s careplans did not identify how the service would minimiserisks. A recent audit of young people subject tosafeguarding procedures had been undertaken. Half ofthe care records did not contain a comprehensive riskassessment and risk management plan.

• The service did not provide out of hours crisis support.Young people and carers did not regularly receiveinformation about how to access support outside ofnormal working hours. Staff said they would make thisclear to a family during the first assessment. Staff sharedcrisis information verbally and did not record when thistook place.Several parents said that if their childbecame very unwell, they would email or call the centre.This meant that young people and parents/carers maycontact the centre when this was not the mostappropriate crisis support. This could lead to a delay foryoung people and carers in receiving appropriatesupport. No incidents had occurred. However, the lackof a robust system for providing information aboutsupport created a risk to young people and carers.

• If the health of a young person deteriorated quicklyduring their treatment, they would refer them to acommunity child and adolescent mental health servicein the NHS for more urgent care.

• When staff received a referral they contacted youngpeople or parents/carers, depending on the youngperson’s age, on the telephone. They discussed thereason for referral and any urgent needs.

• Safeguarding procedures for the service were robustand staff were trained in safeguarding children levelsone, two and three. Staff knew how to escalatesafeguarding concerns and the service kept an eventregister for safeguarding concerns. There was anup-to-date safeguarding policy in place.Staff carried outregular audits of safeguarding practice. In depthanalysis and action plans were shared with the widerstaff group. Staff were able to access specificsafeguarding information in some of the teams, such asthe acute trauma and complex cases court services. Thiswas due to the frequency of safeguarding concerns inthese teams. There was information about safeguardingprocedures displayed in staff offices.

• The centre had a lone working policy which was clearand outlined the requirements for staff during acommunity visit, for example contacting the centrewhen the visit had ended, Staff were aware of this policyand the actions required of them.

• We looked at eight employment records for staff. Wefound that the centre did not have records of up-to-datedisclosure and barring service (criminal records) checksfor two members of staff. These checks ensureemployers can make safe recruitment decisions toprevent unsuitable people from working with vulnerablepeople.A further five of the eight records showed staffstarted work at the centre before their DBS check hadbeen returned to the centre. Staff had started workbetween one and nine days before their DBS checkswere returned. We brought this to the attention of theprovider who took immediate action and reviewed allDBS records for clinical staff. This showed that thesystems to ensure all staff had a valid DBS checks in linewith centre policy was not sufficient.

Track record on safety

• There were no serious incidents which met NHSCommissioning Board criteria in the 12 months beforethe inspection.

• The service kept three risk event registers coveringsafeguarding, complaints and incidents. Management



Good –––


staff had introduced the risk incident register as they feltthe previous incident recording system did not fit theneeds of the service. The clinical governance leadershipboard reviewed these registers each month.

Reporting incidents and learning from when things gowrong

• Staff were aware of how to report an incident and filledin an incident form. Staff internally reported incidentsthat should be reported.

• The service had not notified the CQC of all reportableincidents in line with statutory requirements in the 12months leading up to the inspection. The centre raised12 safeguarding concerns with the local authority on2015 and had one incident involving the police in March2016 and had not notified the CQC of these. This washighlighted to the centre on the day of the inspectionwho took immediate action to ensure this would takeplace.

• The clinical director completed monthly risk reports.These reports described incidents and hadrecommended actions. The report highlighted whoshould carry out the actions and by when.

• There was evidence of change being made within theservice as a result of feedback from incidents. Thisincluded changes to policies to make services moreeffective. For example under exceptional circumstancesstaff could use encrypted memory sticks off site in orderto access information. This was because remote accesswas slow and had meant a clinician could not accessnotes during court for one case. Staff said thatinformation about safety issues were cascaded downvery effectively. Staff were aware of recent incidents thathad occurred.

• The centre did not provide staff with specific training onthe duty of candour, although it was referenced inseveral policies that staff had access to.

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

Good –––

Assessment of needs and planning of care

• Staff wrote and stored information about care oncomputers. Each young person had a separate case file.Each case file should have had four folders ofinformation. These were a folder for case managementinformation, such as the referral and records of consent.A folder for outcome measures and patient feedback. Afolder for clinical events such as risks and supervision,and a folder for correspondence with families andexternal organisations. Complex cases court servicerecords also had one additional folder of informationwith a letter of instruction from a solicitor. A letter ofinstruction outlines what is required from clinicianswhen they are involved in family court proceedings.

• Electronic records did not contain the requiredinformation about care. We saw comprehensive writteninformation about the plan for care in one of six records.In the remaining five records there was no informationabout the plan for care. For one young person who hadbeen with the service for years, there was no record ofthe plan for care in their notes. For another youngperson, supervision notes contained two sentencessummarising discussion with the young person aboutcurrent issues. These were not related to a plan for care.Other information in care records was not completed,for example one young person seen by the schoolsoutreach team only had four of seven pieces of requiredinformation recorded in their clinical event notes. Forone young person, their date of entry to the service wasnot available as staff had not completed forms. The lackof information meant there was no evidence that staffdelivered personalised, holistic and recovery orientatedcare. Before January 2016 staff kept paper records sowere new to the system of electronic record keeping.Staff said that the system was new and differentclinicians completed different levels of information.Management staff checked case files for informationand regular care note audits were in place, however thishad not resulted in staff recording informationappropriately.

• Records did not show that all staff regularly reviewedthe plan for care. In two records, staff had recorded a



Good –––


review of care in March 2016 within the supervisionnotes for the case. These lacked detail and did notreference whether the young person had goals set or ifthey were meeting them. For one young person theirlast review had taken place in November 2011.

• An action plan, including regular audits and thedevelopment of case note standards, was in place toimprove the quality of record keeping. This had been inplace since January 2016 when the service moved frompaper to an electronic record system.

• There was a record of informed consent to treatment inone of six records. This record contained two consentforms, one for consent to treatment and one for consentto the sharing of information with external agencies. Wefound goal based outcomes completed in one caserecord. This was for a young person being supported bythe school outreach team.

• Assessments did not include questions about physicalhealth needs and cultural and religious needs. TheRoyal College of Psychiatrists Quality Network forCommunity CAMHS recommends these areas arecovered as part of holistic assessment and treatment.

• Information needed to deliver care was stored securelyon computers that only staff could access. Any paperrecords were stored securely.

Best practice in treatment and care

• The centre was able to offer a range of psychologicaltherapies recommended by the National Institute ofClinical and Health Excellence (NICE). Research carriedout at the centre had directly contributed to NICEguidance. A number of clinical staff had been membersof NICE guidance groups. The centre had been involvedin using several new models of intervention, for examplementalization based treatment (MBT). MBT is anevidence based psychological therapy for borderlinepersonality disorder and the centre had trained over5,000 practitioners in the UK and overseas in MBT.

• At the time of inspection the centre had made changesso that specialist sub teams were grouped together intotwo main service lines. These were called helpingfamilies services and trauma and maltreatment services.Six specialist sub teams were available in the helpingfamilies services. Five specialist sub teams wereavailable in the trauma and maltreatment services.

Management staff had made these changes to improveworking between sub teams and let staff share theirexpertise with more colleagues. Staff said themanagement team had sought staff feedback about thechange and felt it had made positive impacts.

• In partnership with a separate service provider thecentre had developed and was implementing a modelof care called THRIVE. The model was based onidentifying a young person’s needs regardless of theirdiagnosis or the severity of the illness. For example,some young people may benefit from support inself-management of their illness and others may benefitfrom extensive support and treatment. The model didnot use the tiered model of care, which is commonlyused in CAMHS to identify a young person’s carepathway. Ten CAMHS across the country had startedusing this model for care.

• Staff used outcome measures and evaluated servicedelivery regularly. The CAMHS Outcomes ResearchConsortium (CORC) was based at the centre. CORC hasover 70 CAMHS members that uses routine outcomemeasures to improve services. CORC staff interpretedand reported outcome measures that services couldshare with service users and commissioners. CORC staffalso compared outcome measures across differentservices, allowing benchmarking.

• Staff used outcome measures to evaluate interventionswith parents. For example parents involved with atraining course for those in temporary accommodationcompleted three forms at the first and last sessions ofthe course. These forms were the Eyeberg ChildBehaviour Inventory (ECBI) and the concerns about mychild questionnaire. Eight parents completed theconcerns about my child questionnaire, sevencompleted ECBI. Results showed a reduction in theseverity of the problems parents were experiencing.Staff also used other methods to review outcomes. Forexample in the contact and residency dispute team staffaudited chronic litigation cases over 18 months andreported the service were able to make contact betweenchild and parent happen in 96% of cases. Staff in thecomplex cases court service did not collect outcomesand wrote a service statement outlining the reasons.These were that staff did not feel it was ethical, as it wasmandatory for families to have contact with the servicesby court ruling.



Good –––


• In the 12 months leading up to the inspection, staff tookpart in over 20 clinical audits or evaluations of service.This did not include audits around the physical healthneeds of young people and parents/carers.

Skilled staff to deliver care

• Teams were made up of a range of professionals fromdifferent disciplines. This included psychotherapists,social workers, play therapists, psychiatrists andpsychologists. Staff were experienced and qualified todeliver care.

• Staff received an appropriate induction to the servicewhen they started. The centre had an induction policy,last updated in April 2016, which included a clearinduction checklist covering the use of equipment,orientation to the site including where policies wereheld and roles and responsibilities. It also had separateinduction requirements for staff in specific roles, such asclinical staff, academic staff and teaching staff. Staff saidthey had had received an induction and thought it hadbeen good, providing them with all the information thatwanted to know. Some members of staff were also ableto have periods of handover from other staff when theyfirst started.

• Staff said they received peer supervision every week tofour weeks. Staff said they could also request additionalsupervision outside of this time if they wanted. Therewas no central recording system for supervision. Thecentre had a clinical supervision and line managementpolicy which outlined what supervision should takeplace and the role of line managers. This policy alsooutlined that staff should record case supervision notesin individual case notes following discussion. Staff saidthey felt not everyone completed this regularly, but wesaw evidence in case notes of staff recordingsupervision discussions. Some of the recording wasbrief and did not give a lot of detail about what wasdiscussed and how the plan for care may or may not beaffected. Administrative staff also received linemanagement supervision on a regular basis.

• Staff took part in annual review and developmentmeetings. 80% of

• Staff had opportunities to attend specialist training runfor external professionals by the centre. On someoccasions a small number of places on training sessionscould be reserved for centre staff. The centre did not

systematically document which staff had attendedwhich training. Several staff gave examples of requestingtraining and being supported to access this by theirmanagers.

Multi-disciplinary and inter-agency team work

• The centre had good working links with externalorganisations and services, for example schools.Parents/carers and staff from schools said when schoolstaff made referrals, they young person was seenquickly, usually within two weeks and it was a verysmooth process from referral to assessment. Feedbackfrom staff in schools was that services weretremendously valuable. They gave examples of howcentre staff had provided support to young people,parents and also staff within their schools which had ledto improved quality of life for the young person, familyor staff member. They were able to make referralsthrough their link contact and said staff would attendmeetings with the school and other agency whennecessary. They said staff explained confidentiality tothem in detail and had an understanding of whatinformation could and could not be shared with theschool. Staff were accessible and available on thephone. One teacher said there was goodcommunication with centre staff and they were alwayswilling to be dynamic to meet the needs of children.

• The centre developed a network for schools andteachers to support the identification and support ofmental health problems in young people. This wascalled Schools in Mind and was free of charge. Thecentre developed several materials and trainingsessions for teachers, including lesson plans. They alsooffered access to a website offering self-help techniquesfor emotions and behaviour for 11-16 year olds. Thecentre’s evidence based practice unit (EBPU) evaluatedthe Targeted Mental Health in Schools initiative whichwas a national initiative led by the Department forEducation. It found that behavioural difficulties inprimary school children could be reduced with mentalhealth support. At the time of inspection the EBPU wereevaluating another programme, Headstart, a Big LotteryFund initiative to improve resilience in young people.

• The centre offered training to health care professionalsin a range of interventions. In 2015 the centre trained2,589 professionals over 87 training events. Of theseevent, 25 were for internal staff. These training events



Good –––


took place across six countries. The centre collectedfeedback on these training events and averagesatisfaction was 4.5 out of 5. In partnership withUniversity College London the centre hosted fivepostgraduate programmes and in 2015 taught 470students Feedback gathered from these studentsshowed they rated their satisfaction with the course as4.5 out of 5.

Adherence to the MHA and the MHA Code of Practice

• Staff did not receive specific training in the MHA and theMHA Code of Practice. Staff said they do not work withpatients who are sectioned under the MHA and in theevent that a MHA assessment was required, this wouldbe requested externally.

Good practice in applying the MCA

• Staff did not receive specific training in the MCA or theMCA Code of Practice. From the end of 2015, the centreintroduced information on MCA to level twosafeguarding training.

• The centre had a service user consent policy, which waslast reviewed in March 2016. This policy outlined validconsent and stated that the centre’s preference was forstaff to obtain written consent to treatment. It statedthat staff should store the form where the service userexpressed their consent in their individual case record.These forms were not present in five of six case notes welooked at. The policy also explained competence,capacity and incapacity and outlined the MCA in detail.

• Staff had a clear understanding of Gillick competenceand consideration of this in practice.

Are specialist community mental healthservices for children and young peoplecaring?

Good –––

Kindness, dignity, respect and support

• Young people and parents/carers were very positiveabout staff and the how they behaved towards them.They said staff were very kind and caring as well asextremely supportive, polite and informative. Parentssaid their children had reacted positively to the staff and

they had seen a change in their child. Young people saidclinical staff were very nice and particularly mentionedreception staff in making the environment welcoming.Young people said it was helpful to always see the sameclinical staff at appointments.

• All young people and parents/carers felt staff listened tothem, although one parent said there had been a fewoccasions where they did feel listened to.

• Most parents/carers and young people said staffexplained confidentiality from the first time they metand understood what this meant. One parent was ableto explain what this meant in detail. One parent saidstaff did not explicitly explain confidentiality to them.Staff did not routinely share written information aboutconfidentiality with young people and parents/carers.

• Parents/carers said they found the service helpful anddescribed it as a brilliant service that had enhancedtheir relationship with their child. Those who hadattended a parent course said it had really changedtheir life. Another described the help they had receivedas had brought them back to life.

The involvement of people in the care they receive

• Parents/carers and young people felt they haddiscussed and developed a pan for care with staff,including discussing various treatment options. Severalparents said staff provided consistent verbal feedbackabout treatment. Two parents/carers we spoke with hada copy of the plan for care. The remaining eight youngpeople and parents/carers said they did not have a copyof the care plan, although they felt they knew what wasgoing on due to discussions with staff. They also saidthey felt they were being offered support, rather thantreatment, so a treatment plan wouldn’t always beappropriate.

• In the six records we looked at, only one included awritten plan for care. We also found that staff did notrecord whether the plan for care had been discussedverbally with the young person or family, meaning staffcould not clearly demonstrate that this was taking placeregularly. In the documents that were available, staffused a large amount of acronyms in the care records,which meant it may have been hard for families andexternal agencies accessing the information to fullyunderstand it.



Good –––


• Parents/carers said staff were really helpful and helpedthem with their own motivation and made referrals toexternal organisations for the family’s wider needs, forexample financial charity organisations. Parents saidstaff were kind and went the extra mile in their work.Parent/carers gave examples of how staff had supportedthem in providing the best care for their child.

• The centre ran several support and intervention groupsfor parents and families. One example was a parentsupport programme called Empowering Parents,Empowering Communities (EPEC). EPEC was run byparents who had been trained in facilitation and threegroups ran at the Homeless Families Hostel in Camden.The groups were for up to 10 parents living in temporaryaccommodation and ran for eight sessions. Anindependent evaluation reported positive changes fromthe beginning and end of the group and parents gavepositive verbal feedback. Parents also carried out theirown audit of the programme and made a film of theirfeedback. The evaluation also showed that 80% ofparents involved completed the course of eight groupsin their at first attempt, one at second attempt afterre-joining the sessions.

• There were four advocacy services available for serviceusers to access. Four parents/carers we spoke with wereunaware they were able to access these services. Twostaff we spoke with were also unaware of the advocacyservices that could be accessed.

• Young people and parents/carers were able to getinvolved in some decisions about the service. Forexample, staff collected service user feedback in relationto the move to a new site in Kings Cross. In a parentpanel meeting, the group discussed the design of thenew campus, for example carpet colour and the level ofinvolvement they were able to have in design.

• Young people and parents/carers were able to givefeedback about the care they received. Most youngpeople and parents/carers said they felt able to do thisand had provided feedback in the past. The centreroutinely collected feedback on the service using theexperience of service questionnaire (ESQ). Staffdisplayed the results in waiting area at the centre. Thosedisplayed at the time of inspection showed that 17children completed the most recent questionnaires and82% felt they had received good help and 94% feltlistened to. Also, 67 parents completed the

questionnaire and 100% felt they had received goodhelp and 97% felt they were listened to. These resultswere compared to averages from several services in thecountry and results for the centre were more positivethan the other services. The centre had a section ontheir website called ‘Have your say’ which encouragedchildren, young people and families to contribute toprojects. For example, a ‘See us Hear us’ project whereyoung people produced a photo that answered thequestion: ‘What or who helps young people when theyare stressed or upset?’

• A parent’s panel met every six weeks. We observed oneparent’s panel. Participation officers facilitated thegroup and there were discussions about futureinitiatives the parent’s panel would be involved in. Anexample was that the panel decided they would puttogether a hostel survival guide for families. After themeeting the service provided a lunch for staff andparents to eat together. Parents were able to expresstheir ideas and have open conversations with staffabout the service. Staff listened to parents and keptminutes and actions for the meeting. Parents felt thatactions from these meetings were not always carriedout in a timely way and that some suggestions did notlead to change. It was not clear how staff communicatedwhich ideas would and would not be put in place andthe reasons behind these decisions. This led to someparents feeling that their ideas were not taken on board.

• Each specialist team within the service had aninformation leaflet that outlined their services. Someleaflets included information about how people couldprovide feedback to the centre about their care, but notall. For example, it was not included on the leaflet aboutparent-infant project.

• Staff also kept informal feedback, such as thank youemails sent to staff from young people and families.

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

Good –––

Access and discharge



Good –––


• Most of the specialist sub teams did not have waitinglists for people to access support. The mentalizationbased therapy for families team had the longest waitinglist of up to six weeks. In the trauma and maltreatmentsub teams, only one of five had a waiting list that wasbetween one and three weeks. This meant youngpeople and families were able to access services assoon as they needed them.

• In the 12 months before the inspection, the servicesupported just over 600 young people and families. Thelength of treatment varied within the teams. Longestinterventions were in in the child psychotherapy andschools outreach service. These were just over one year.The court services offered appointments once or twice aweek over 10-12 weeks. Case loads were broken downby team. The team with the largest case load were theschools outreach team. Seven staff with a total of 175clinical hours per week worked in this team.

• Parents/carers and young people said they were seensoon after they had been to their GP. One parent saidthe clinician came to visit them and their child in thecommunity before their first assessment. Other parents/carers said staff contacted them on the phone beforethe first appointment. One parent/carer who hadaccessed different sub teams of the service said it waseasy to transfer their care from one to another.

• Referral forms included a clear payment structure basedon a family’s income.

• Parents/carers said staff were available over the phone ifthey wished to speak to them outside of appointmentsor rearrange appointments. They said if a message wasleft with reception, the staff always called back.

• Not all sub teams had clear eligibility criteria for theirservices. Some outlined these, for example the childpsychotherapy service outlined criteria or age, how farthe family lived from the centre and the emotional orbehavioural issues that the service could support, butfor others, this was not recorded anywhere. Staff saidthere were not strict criteria in place across the teams.

• Where possible, staff offered flexibility in times ofappointments. The service was open until seven pm.Reception staff worked from 7.30am until 6pm. Parents/carers said they were able to choose an appointmenttime that worked for them. Staff from local schools saidcentre staff were able to offer children and young

people appointment times after school. One parent saidstaff would give a lot of notice if an appointment had tobe cancelled and explain the reason why. They saidappointments would be rearranged and this call wouldbe made by the clinician themselves.

• Some sub teams, for example the family assessmentservice, monitored contact with young people andreported in this. This meant they were able to identifyhow long people accessed the service for, but theycould also see when people did not attendappointments. Staff produced these reports every sixmonths and they were available from 2011 onwards.The report from April to September 2015 showed whenchildren came alone, they attended 85% ofappointments, when children were brought by theirparents they attended 95% of appointments and whenparents came alone they attended 77% ofappointments.

The facilities promote recovery, comfort, dignity andconfidentiality

• The waiting room was welcoming and provided severalareas of comfortable seating. There were toys and otherresources available that were appropriate for childrenand young people of a range of ages. During theinspection we saw that reception staff were verywelcoming to visitors.

• The service had over 10 therapy rooms available.Administrative staff managed the booking of theserooms. Staff said there was not a problem in booking aroom when one was needed as there were enough toaccommodate the centre’s needs. All rooms had signs toindicate whether they were vacant or engaged sotherapy sessions would not be disturbed. There weretoys and resources available in some rooms and also aresource cupboard where extra toys were stored.Several rooms did not contain toys and would be usedto meet with adolescents. There were rooms availablewith one way mirrors and recording equipment forfamily therapy work. There were several rooms on thelower ground floor of the building for training eventsand staff meetings that could fit up to 100 people. Therewere also several smaller rooms that could be used astherapy rooms or breakout rooms during training.



Good –––


• There was a baby changing room available. This was onthe same floor as therapy rooms used for babypsychotherapy.

• There were information leaflets about the serviceavailable near the front door, just outside the reception.They were written clearly and explained what serviceswere in the centre and how to contact them.

• Parents/carers and young people said staff providedthem with a lot of information about who they werecoming to meet before their first appointment. Theysaid staff were clear with them about what wouldhappen at the first assessment.

• Parents/carers and young people said staff providedverbal information about the treatment they offered.They did not provide any written information, which theparents/carers and young people said was fine at thetime. They said staff were always available to speak to,so not having written information was acceptable.

• The centre had a website that was young personfriendly and informative. The website was designed so itcould be used on mobile phones and providedinformation about the services at the centre as well ascontact details and links for sources for support. Thiswas provided in writing and video format. The websiteincluded links to relevant and up to date news articlesand podcasts from centre staff, young people using theservice and professionals in partner agencies. Thewebsite also outlined the centre’s vision of ‘a world inwhich children and their families are effectivelysupported to build on their own strengths to achievetheir goals in life.’ Parents who had accessed the websitesaid they found it very helpful.

• The Evidence Based Practice Unit of the centre alsosupported the development of several web-basedsupport resources by young people. Examples were TheMy CAMHS Choices website which explained the CAMHSprocess for young people thinking of getting mentalhealth support. The website also linked to a Twitteraccount meaning it could engage with a large number ofyoung people in this way. Also, Include-Me was aninteractive website to support children and youngpeople already accessing CAMHS across England.

Meeting the needs of all people who use the service

• The service was accessible to people requiring disabledaccess. There was a ramp which allowed access to thelower ground floor which had several rooms available aswell as a bathroom for those with a disability.

• Not all information leaflets included information aboutwhether they were available in other languages or indifferent formats, for example in an easy read format orbraille. Staff said that when they identified that a familyneeded information in another language, this was doneusing interpreter services. This was not made clear oninformation leaflets.

• The centre website was designed to be compliant withguidelines to ensure it could be accessed by partiallyblind people. It also had contact details available forpeople to make comments or queries relating toaccessibility of the website. The website did notmention providing information in different languages orfor people with a learning disability.

• Staff were able to access interpreter services.

Listening to and learning from concerns andcomplaints

• The service managed complaints well. Staff were able todescribe how to manage a complaint. In sevencomplaints from 2015 and 2016, staff responded to all ina timely way and within the target time of 15 days, asoutlined in their complaints procedure. Responses wereappropriate, for example staff offered a phone call orface to face meeting to discuss the complaint. Theservice stored complaints in a folder and thisinformation showed staff communicated well with eachother about the management of complaints. Staff saidthe

• The centre website had a section for complaints andstated the centre welcomed feedback of any kind. Therewas a link to a complaints leaflet that gave step-by-stepguidance on how to make a complaint and how longthe centre would take to reply.

• Not all parents/carers we spoke with were aware of theformal procedure to make a complaint, but wereconfident they would be able to find out from staff ifnecessary.

• There was a centre document outlining how parents,young people and children were able to providefeedback and raise complaints. It was last updated in



Good –––


March 2016 and was due to be review date November2016. It was written for a young person or familymember rather than staff and included information onhow to make a formal complaint. It was not clearwhether this was a document that was regularly sharedwith people using the services.

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

Good –––

Vision and values

• The values of the centre were to be inspirational,pioneering, involved and determined. Staff said theyliked working at the centre and felt proud to do so. In a s

• Staff knew who the most senior managers were and saidthere was good leadership in the centre. They felt seniorstaff were visible and were aware of ideas to improvethe links between the board and clinical staff. Staff feltthe recent reconfiguration to make two overarchingservice lines had made a positive impact on the centre,for example it had increased opportunities for sharedlearning. The staff survey in July 2015 showed a third ofthe staff felt opportunities for this were not sufficient.

Good Governance

• There were clear lines of reporting and responsibility forincidents, complaints and safeguarding issues.Information was presented and assessed throughseveral oversight groups. They had an on-goingprogramme of revising and updating policies aboutgood and safe practice within the centre. All policies andprocedures are available to staff on the intranet. Theclinical director wrote a monthly risk report on three riskevent registers summarising an event and the actionsand learning from it. This had been in place for twomonths and risk reports were available for March andApril 2016. This provided ongoing updates of risk andlearning from incidents within the service.

• The governance processes had not identified the needto improve the robustness of recruitment checks,mandatory training and thorough completion ofelectronic patient records.

• A central support team for the organisation was basedon site and was made up of service such as humanresources, finance, training and administration.Administrative staff provided support across all clinicalsub teams. Clinical staff said the central administrativeteam provided fantastic support and very high qualitywork.

Leadership, morale and staff engagement

• There were very low rates of sickness and absenceacross the centre. Staff were aware of thewhistleblowing policy and said they felt able to voiceconcerns without fear of victimisation.

• Staff said morale was good and they were happy to workat the centre. They said there was a real focus on drivingthe centre forward and making improvements. Theysaid there was a strong culture and everyone caredabout the centre. Results from a s

• Staff said they felt supported in their roles andcolleagues were approachable and helpful. Clinical staffsaid they felt their professions were valued. Staff saidstaff worked well together and they were able toapproach their direct managers and the clinical directorto voice ideas. Staff said it was a good place to work andpeople were enthusiastic in taking things on.

• Staff were offered opportunities to give feedback aboutservices and input into service development. The centreundertook regular here was evidence that senior stafftook on board feedback from staff, for example sixchanges were introduced following the last staff survey.One change was the development of a new continuingprofessional development

Commitment to quality improvement and innovation

• At the time of inspection the CAMHS OutcomesResearch Consortium was developing accreditation forservices and the centre would carry out a self-reviewagainst CORC standards in 2016. The centre alsodeveloped and hosted the Youth Wellbeing Initiative,devised the Youth Wellbeing Directory. This was anaccreditation network for voluntary sector organisationsworking with children, young people and families withsocial and emotional needs. Services would beaccredited using ACE-Value standards.

• The centre took part in and published research paperslooking at a range of their interventions. For example



Good –––


they took part in a randomised control trial ofparent–infant psychotherapy for parents with mental

health problems. The centre published 21peer-reviewed papers in 2015. Staff from the parenttoddler group wrote a chapter in a book about apsychoanalytic developmental approach to care.



Good –––


Outstanding practice

The centre had a website and other online resourcesoffering a wide range of information about mental healthand support available. This website was created with theinput of young people and meant the centre couldengage with and support young people in an appropriateand relevant format.

The centre was involved in developing and implementingmodels of care and intervention that had been rolled outacross other services in the country. For examples theTHRIVE model of care.

Areas for improvement

Action the provider MUST take to improve

• The provider must ensure mandatory trainingcourses include those staff can use to maintain thesafety of patients. This includes fire safety, infectioncontrol, basic first aid, Mental Capacity Act trainingand training in the Children Act 2004.

• The provider must notify the Care QualityCommission of incidents in line with statutoryrequirements.

• The provider must ensure all staff have an up to dateDisclosure and Barring Service check and have asystem in place to monitor this.

• The provider must ensure that information for youngpeople and families about how to access help in acrisis, including out-of-hours, is provided in writing.

• The provider must ensure that risks identified in arisk assessment are included in a care plan to outlinehow the risk will be managed. The provider mustensure staff regularly update risk assessments.

Action the provider SHOULD take to improve

• The provider should ensure that staff record whencleaning toys and resources has taken place andhave a system in place to monitor this.

• The provider should review the governanceprocesses to ensure they cover all the necessaryoperational areas of the service, for examplerecruitment checks, mandatory training andthorough completion of electronic patient records.

• The provider should ensure that parents/carers andyoung people can access information in a languageor format most helpful to them.

• The provider should ensure that staff record informedconsent in line with the centre’s policy.

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 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Care and treatment must be provided in a safe way forservice users.

Staff had not received a comprehensive programme ofmandatory training.

Staff did not regularly review and update riskassessments.

Staff did not regularly provide written information abouthow to access support outside of normal working hoursand in a crisis.

This was a breach of Regulation 12(1)(2)(a)(b)(c)(h)

Regulated activity

Treatment of disease, disorder or injury Regulation 18 CQC (Registration) Regulations 2009Notification of other incidents

The provider had not submitted all necessary statutorynotifications to the CQC in the past 12 months.

This was a breach of Regulation 18(2)(e)(f)

Regulated activity

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

The provider did not have sufficient systems andprocesses in place to ensure that all staff had up-to-dateDisclosure and Barring Service checks.

Regulation

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


This was a breach of Regulation 19(1)(2)(3)

This section is primarily information for the provider

Requirement noticesRequirementnotices


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