CQC Draft Inspection Report – Formal Response and Clarifications

16/04/2025

Introduction

At I Straker Consultants Ltd, we fully support the role of the Care Quality Commission (CQC) as a vital body in protecting the public from unsafe or unethical healthcare practices. We recognise the importance of independent regulation and welcome scrutiny that is fair, evidence-based, and consistent across the sector.

However, we are deeply disappointed by the content and outcome of our recent draft assessment. While we maintain high clinical standards and are committed to continuous improvement, the report contains multiple factual inaccuracies, procedural inconsistencies, and misrepresentations of both our service model and the evidence presented during inspection.

We believe the assessment fails to reflect the quality, safety, and impact of the work we deliver. More concerningly, elements of the process suggest the potential for procedural bias—or at minimum, a serious failure in internal oversight—raising questions about the integrity and transparency of the outcome.

We set out below our full response to the draft report. It includes a line-by-line factual accuracy challenge, based on the evidence provided and the standards we uphold for the clients we serve.

**Update** 03/04/2025

Update on CQC Response

Despite providing the Care Quality Commission (CQC) with a comprehensive and detailed response—clearly highlighting procedural failings, factual inaccuracies, and scoring errors—the CQC did not revise a single score in our favour. This is particularly concerning given that our ratings for both the “Safe” and “Well-led” domains were 38% and 36%, respectively. According to the CQC’s own published guidance: “A quality statement score of 37% or higher rounds to Requires improvement” (CQC Reach Rating Guidance).

While the CQC did acknowledge and accept some of the points we raised, they ultimately chose not to amend the scoring in any way that would reflect those corrections. In fact, in reviewing our response, the CQC appeared to reassign or remove scores from other areas—effectively ensuring that the overall outcome remained at “Inadequate.” This suggests a concerning degree of rigidity in the process and raises questions about whether the scoring system is being used to justify predetermined outcomes, rather than respond to transparent and evidence-based engagement.

CQC Inspection Statement

Overview

Overall Rating:

Safe: Inadequate - 38%

Well-led: Inadequate - 36%

Overall Service Commentary

We inspected I Straker Consultants Ltd on the 17, 18, 21 and 22 October 2024. The service was originally registered as Horton House in May 2023. The service subsequently moved to a new location, registered as I Straker Consultants Ltd which was registered in September 2024. The service had not previously been assessed or rated. The service is registered for the regulated activity of treatment of disease, disorder or injury. During this assessment we assessed all 15 quality statements across the safe and well led key questions. Following our assessment, we issued the provider with two s29A warning notices under regulation 12 (safe care and treatment) and regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We identified concerns regarding: The qualification and training of staff and the processes to assure their competency, Safe prescribing of medication, The lack of effective governance and quality assurance processes.

Overall People's Experience

During our assessment we spoke to one service user onsite and received feedback from two other service users during the assessment process. In addition, we also reviewed feedback from service users on the providers website and from independent patient review websites. Feedback from service users was mixed. Some service users provided positive feedback on the service they received and the staff who supported them. They considered the service to be responsive and caring. However, we also received feedback from service users who described negative experiences. These included concerns over assessment and prescribing processes as well as effective communication.

Our response:

In reviewing the Care Quality Commission’s recent report on our service, we are compelled to raise serious concerns regarding the lack of consistency and objectivity in its methodology and reporting. Notably, the inclusion of selected Google reviews—some of which contain unverified, anecdotal opinions—represents a clear deviation from the CQC’s usual practice. In three other reports for comparable services offering online ADHD assessment and treatment, no such user reviews were cited whatsoever.

It is particularly troubling that our organisation, which holds a 4.7-star rating, has been singled out for criticism based on a small handful of public reviews, while other providers with lower ratings (e.g., 4.5 stars) received a Good rating without any reference to online feedback. This inconsistency undermines the credibility of the CQC’s assessment process and raises serious questions about fairness and impartiality.

Furthermore, we find it wholly disproportionate that the CQC’s conclusions regarding client experience were drawn from conversations with only three individuals—a mere 0.1% of our total client base of over 3,000. It is statistically indefensible to present such a limited and potentially non-representative sample as reflective of the wider service provision.

We assert that this approach lacks both transparency and balance, and we formally request clarification as to why our organisation was subjected to a reporting standard that appears inconsistent with those applied to peer organisations.

Safe

Rating: Inadequate

Percentage Score: 38.00 %

Summary

This service is not safe

Commentary

We rated safe as inadequate. We assessed 8 quality statements. Staff were not always suitably qualified or trained to complete assessments and medical reviews. There was no process to assure their competency in these roles. The service did not ensure staff followed policy to ensure that relevant service user history was sought from their regular prescribers to ensure controlled drugs could be safely prescribed. The service did not have a robust process for the management of prescription stationary. However, the environment was clean and well maintained. Staff had completed safeguarding training and processes were in place to raise safeguarding concerns.

Our response:

We categorically challenge the CQC’s representation regarding the regulation of our assessment activity. ADHD assessments, as provided by our service, do not constitute a regulated activity under the Health and Social Care Act 2008, and therefore should not have been included in the regulatory scope of the inspection report. We request the immediate removal or amendment of this inaccurate assertion, which demonstrates either a misinterpretation of statutory guidance or a selective application of regulatory criteria not imposed on comparable providers.

Furthermore, the CQC’s commentary on staff qualifications fails to acknowledge the robust, transparent, and clinically aligned recruitment and training procedures that are firmly embedded within our service. Our staff are specifically recruited for their transferable skills in therapeutic engagement, a core requirement that is clearly outlined in our job descriptions and explored extensively during structured interviews.

Contrary to the misleading impression given in the report, all new staff undergo a mandatory induction and training programme, including:

Structured shadowing,
Internal training aligned with UKAAN protocols,
Ongoing clinical supervision and peer support, and
Continuous guidance in line with RCP and NICE standards.

Not only was this detailed process clearly explained during inspection, but supporting documentation was also provided — evidence which appears to have been disregarded or omitted from the final report without justification.

It is deeply concerning that such essential context and supplied evidence have been overlooked or excluded, thereby presenting a skewed and misleading account of our clinical standards and governance. We urge the CQC to reconsider the accuracy and integrity of this section of the report and ensure that parity is applied across all providers subject to inspection.

Prescriptions:
This claim significantly misrepresents the security protocols in place at the time of inspection and disregards both the context and standard operating procedures (SOPs) that were followed and shared with the inspection team.

At the time of inspection, the prescription cabinet in question was observed within a locked manager's office, which itself is:

Located within a locked main office,
Inside a fob-access-only service,
Within a double-locked external building accessible only to management outside of operating hours.

The cabinet in question had the key temporarily inserted in the lock, attached to a staff lanyard, as is standard practice during working hours while staff are physically present in the room. The Registered Manager clearly explained that this was an active working session, not an unattended or insecure environment. It is disingenuous to present this situation as a breach of safety protocol, particularly when no unauthorised access was possible and the key was under the direct supervision of present staff.

Furthermore:

Our prescription log is fully maintained and accessible via the PCSE portal, as well as recorded on each patient’s individual prescription card, ensuring full traceability and accountability.
Our void prescriptions were stored securely. While it is correct that the destruction folder was full at the time of inspection, the guidance permits retention for up to three months — a detail that was explained and appears to have been ignored. The volume of void prescriptions present was entirely in line with this guidance and consistent with expected service volume.

By omitting this context, the report presents an unjustifiably negative narrative and implies procedural failings where none existed. We request the CQC correct this section of the report to reflect:

The physical security measures in place,
The valid reasoning for prescription handling,
And the correct interpretation of retention guidelines for void scripts.

Safe

Learning Culture

Overall Score - 1

This score has been adjusted by CQC.

Read about why we adjusted scores: https://www.cqc.org.uk/guidance-regulation/providers/assessment/assessing-quality-and-performance/reach-rating

We have moderated the scoring of some of the quality statements within the key questions Safe and Well-led to give an overall rating of Inadequate for both key questions. This is to reflect the serious nature of the breaches identified under Regulations 12 and 17, for which the warning notices were served.

Summary
Inadequate – This service does not maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

People's Experience

Score: 3

Service users that we spoke with and received feedback from did not raise any concerns regarding incident management. Service users we spoke with had not been involved in a serious incident or an incident that had required further feedback. None of the service users we spoke with had raised a formal complaint.

Feedback from Staff and Leaders

Score: 1

Staff we spoke with told us they would inform management of any issues or incidents that occurred. Staff were able to describe who they would report different incident types to. For example, any incidents related to health and safety or acts of aggression were reported to the service manager. Clinical incidents were reported to the lead prescriber. Staff told us that incidents were reported verbally and there was not a specific system or form to complete.

Incidents were discussed in daily meetings. Managers we spoke with told us that incidents were also discussed in the weekly management team meeting which was minuted and shared with staff. Staff we spoke with told us that there were not many incidents that required reporting.

Processes

Score: 1

The service did not have a specific system or documentation to report incidents. Incidents were reported verbally and not formally captured on an incident reporting system. There was no log of reported incidents.

The service did have a log of complaints that had been received which included the outcome and agreed resolution where appropriate. There was a complaints policy in place. Staff sought to resolve complaints informally before the formal complaints policy was invoked.

There was a copy of the service’s complaints policy available on the service’s website. Discussions around reported incidents and complaints were held with staff in the daily meeting; this included feedback on any findings or agreed actions. There was space for managers to discuss incidents and complaints in a weekly management meeting.

Our response :

CQC Statements in Report:
“The service did not have a specific system or documentation to report incidents. Incidents were reported verbally and not formally captured on an incident reporting system. There was no log of reported incidents.”
“Learning and culture rated 1. Feedback from staff and leaders rated 1. Processes rated 1.”

Our Challenge:
These statements are factually incorrect and directly contradict both the evidence provided during inspection and the CQC's own summary of staff responses.

Electronic Incident Reporting System and Tracker
The service has a formal, operational incident reporting system in place. This includes:
- Electronic reporting of all incidents through a secure internal platform.
- A comprehensive incident tracker, which was shown and submitted to the CQC inspection team at the time of the visit.
- Verbal reporting may occur as an initial notification (particularly for low-level matters), but this is always followed by a written electronic statement and documented escalation. The suggestion that incidents are "only reported verbally" is patently false.
Structured Governance and Oversight
Incident management is embedded across multiple organisational layers, including:
- Daily Multidisciplinary Team (MDT) meetings,
- Weekly Management Team Meetings,
- Monthly Staff Meetings,
- Monthly Senior Leadership Meetings.

These forums include formal agendas, minuted outcomes, and follow-up actions. The claim that incidents were not formally discussed or reviewed is baseless.

Complaint Handling and Documentation
The service maintains a log of complaints, which was submitted to inspectors. The log includes:
- Complaint summaries,
- Outcomes,
- Actions taken and resolutions agreed, in accordance with our written policy.
  Additionally, our Complaints Policy is publicly available via our website — this was also acknowledged in the report itself, yet incongruously downplayed in the scoring rationale.
Contradictory Internal Reporting by the CQC
The inspection narrative itself states that:
- “Staff were able to describe who they would report different incident types to.”
- “Incidents were discussed in daily meetings.”
- “Managers told us incidents were discussed in weekly management team meetings which were minuted and shared with staff.”

These statements are clear indicators of a structured and active incident reporting culture, directly undermining the conclusion that there is no formal process or documentation. Assigning a score of 1 to “Learning and Culture” and “Feedback from Staff and Leaders” in light of this admission is inconsistent and unjustified.

Requested Amendments:

Acknowledge the existence and operation of the electronic incident reporting system.
Amend the scoring for Learning and Culture, Processes, and Feedback from staff and leaders, based on the factual evidence provided.
Rectify the contradiction between reported staff feedback and the scoring justification.

We respectfully request that this section of the report be updated to reflect the true state of our governance, reporting, and cultural learning processes, and that the associated ratings be revised accordingly.

Safe

Safe Systems, Pathways and Transitions

Overall Score - 1

Service users had either self-referred into the service or been referred by a medical professional. We did not speak to any service users who had been transferred to shared care. However, we spoke to service users who were undergoing medicine optimisation at the service who told us that they had been provided with information around the shared care process and how and when they would be transferred.

Feedback from Staff and Leaders

Score: 1

Staff told us that the service had systems and pathways in place to work with GPs. Managers told us that there was a process in place to request information from a service user’s GP before commencing prescribing. They told us that prescribing should not begin until that information had been received.

However, some staff we spoke with told us that information was not always sought, or received prior to patients being prescribed. Our review of records confirmed this.

Staff we spoke with were able to describe the process for referring service users to shared care once they had been titrated and stabilised on medication. They understood at what point in the treatment process referral should begin and were able to discuss the options available to service users where shared care either wasn’t an option or had been declined by the GP.

Feedback from Partners

Score: 3

We did not receive feedback from partners.

Processes

Score: 1

There was a process in place to request patient information from GPs prior to commencing treatment. However, we reviewed five records and found that only one record had a full patient summary in place. In the other records there was either no evidence of a request for information or prescribing had been started without the information being received.

There was a shared care protocol in place to support staff. The service maintained a shared care log to detail which patients had been referred and which patients had their prescribing transferred to their GP under shared care arrangements.

The service had a certificate of diagnosis document that was sent to GPs as part of the transfer of care.

Our response:

Inconsistent and Unsubstantiated Scoring – Safe Systems, Pathways, and Transitions

CQC Scoring:

Safe systems, pathways and transitions – Rated 1
People’s experience – Rated 1
Feedback from staff and leaders – Rated 1
Feedback from partners – Rated 3
Processes – Rated 1

CQC Narrative:

“Service users we spoke with and received feedback from did not raise any concerns in relation to safe systems, pathways and transitions.”
“We spoke to service users undergoing medicine optimisation who told us they had been provided with information around the shared care process.”
“Staff told us the service had systems and pathways in place to work with GPs.”
“The service had a shared care protocol and maintained a shared care log.”
“The service had a certificate of diagnosis document that was sent to GPs as part of the transfer of care.”

Our Challenge:

The narrative presented by the CQC is factually inconsistent with the scores assigned. The report itself outlines multiple systems in place, user satisfaction, and staff understanding of appropriate protocols — yet scores all elements as “1” without clear justification. This is arbitrary and unsupported by the evidence recorded in the inspection.

Service User Feedback – Rated 1 (Unjustified)
The report explicitly states that:

No service users raised any concerns about safety, systems, or transitions.
Service users had been properly informed about shared care pathways and transition processes.

Why then is People’s Experience rated a 1 when the evidence presented by the CQC indicates no user dissatisfaction or identified risks? This score is incongruent with both user feedback and internal processes. We formally request this score be amended to reflect the positive user engagement and reassurance provided.

Staff and Leadership Feedback – Rated 1 (Unjustified)
The CQC confirms that:

Staff understood and could articulate the referral and shared care process.
There was a defined process for requesting GP summaries prior to prescribing.

Yet a rating of “1” is given based on five handpicked records — four of which allegedly lacked full GP summaries — with no indication of clinical risk or harm in those cases. This isolated documentation issue does not justify a score of 1 across all feedback from staff and leadership. It is disproportionate and lacks nuance. Furthermore, feedback from staff aligned with expected practices, and governance structures (such as shared care protocols and documentation trails) were in place and evidenced.

Process – Rated 1 (Unjustified)
The CQC acknowledges:

A shared care protocol exists,
A log is maintained for all shared care transitions,
A Certificate of Diagnosis is used consistently,
GP engagement processes are documented.

To conclude a score of “1” in “Process” despite confirming the existence of multiple working systems is an unsupported contradiction. We acknowledge that in a small sample of five records, four lacked complete GP summaries — however, this does not amount to a systemic failure. We request this rating be reassessed in line with proportionate inspection principles and the wider evidence base.

Safeguarding – Inconsistently Scored
The report states we were scored a 3 on each mark, yet received an overall rating of 2.
Why was the overall rating downgraded despite all sub-criteria being met at level 3? This requires formal clarification and reconsideration.

Involving People to Manage Risks – Rated 1 (Unjustified)
There is no narrative explanation justifying this score, nor any recorded evidence suggesting that people were not involved in managing risk. On the contrary:

Service users reported being well-informed about transitions and shared care planning,
Staff described the communication pathways and referral options accurately,
Documentation exists to show process adherence and informed service delivery.

We request that this score be re-evaluated based on the absence of negative user experience, staff knowledge, and existing documented safeguards.

Summary of Requested Amendments:

Domain	Score Given	Challenge	Requested Amendment
People’s Experience	1	Contradicts own findings, no user concerns reported	Amend to 3
Feedback from Staff and Leaders	1	Evidence shows staff understood and followed protocol	Amend to 3
Processes	1	Shared care protocol, log, and systems were in place	Amend to 3
Safeguarding	2	All marks were 3 – clarify why reduced	Clarify/amend to 3
Involving People to Manage Risks	1	No evidence of failure to involve people provided	Amend to 3

We expect consistency and fairness in the application of scoring criteria. The conclusions drawn and the associated ratings lack proportionality and do not accurately reflect the factual evidence presented and acknowledged during inspection.

Safe

Safeguarding

Overall Score - 2

This score has been adjusted by CQC.

Read about why we adjusted scores: https://www.cqc.org.uk/guidance-regulation/providers/assessment/assessing-quality-and-performance/reach-rating

We have moderated the scoring of some of the quality statements within the key questions Safe and Well-led to give an overall rating of Inadequate for both key questions. This is to reflect the serious nature of the breaches identified under regulations 12 and 17 for which the warning notices were served.

Summary

Requires Improvement – This service generally maximises the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

People's Experience

Score: 3

Service users we spoke with and received feedback from did not have any specific safeguarding concerns and were not involved in active safeguarding processes.

Feedback from Staff and Leaders

Score: 3

Staff we spoke with confirmed they had completed safeguarding training as part of their induction and ongoing mandatory training requirements. They demonstrated a good understanding of safeguarding issues and were able to describe different types of abuse and what constituted a safeguarding concern. Staff knew who to contact for advice within the service and understood the process to raise a safeguarding concern internally and to the local authority.

Observation

Score: 3

We did not review any assessments where a safeguarding concern had been identified or actioned. We did not identify the need for a safeguarding in those records. We observed a daily staff meeting and saw that safeguarding was considered as part of the standard agenda. However, there were no new safeguarding concerns to review as part of the meeting.

Processes

Score: 3

Staff completed safeguarding training as part of their mandatory training programme. Staff completed separate courses covering the safeguarding of adults and the safeguarding of children. At the time of our assessment, compliance with both safeguarding training courses was 100%.

There was a safeguarding policy in place. The registered manager was the identified designated safeguarding officer for the service. Safeguarding and safeguarding concerns were a standard agenda item on the daily staff meeting.

Our response:

Safeguarding

CQC Narrative:

“Service users we spoke with and received feedback from did not have any specific safeguarding concerns.”
“Staff we spoke with confirmed they had completed safeguarding training as part of their induction and ongoing mandatory training requirements.”
“They demonstrated a good understanding of safeguarding issues and were able to describe different types of abuse and what constituted a safeguarding concern.”
“Staff knew who to contact for advice within the service and understood the process to raise a safeguarding concern internally and to the local authority.”
“Safeguarding and safeguarding concerns were a standard agenda item on the daily staff meeting.”
“Staff completed separate training in adult and child safeguarding, with 100% compliance at the time of assessment.”

Our Challenge:

The CQC’s own narrative outlines a clear and robust safeguarding framework:

No safeguarding concerns were identified by service users or found in the records reviewed.
All staff are 100% compliant with safeguarding training (both child and adult).
Staff demonstrated a strong understanding of safeguarding and appropriate escalation processes.
Daily safeguarding discussions were embedded in team meetings.
A dedicated safeguarding lead is in place, with a policy available and followed.

Given this, we strongly challenge the score of 2 overall.

We request this score be amended to reflect the evidence — a rating of 3 is appropriate, based on user safety and lack of identified safeguarding risk.

We request that this section be amended to reflect the documented strength of our safeguarding systems, the competence of our staff, and the absence of any active concerns. The current scoring is not only inconsistent with your own narrative but fails to reflect a fair and proportionate assessment of our safeguarding practices.

Safe

Involving People to Manage Risks

Overall Score - 1

Summary

Inadequate – This service does not maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Peoples Experience

Score: 2

Service users we spoke with and received feedback from during our assessment process provided mixed feedback on the management of risk. The majority of feedback we received was positive and those service users felt that their risks were well managed and that they were given advice and information to support them. However, some feedback we received and reviewed was less positive. Some service users felt that their potential risks were ignored or not considered within the assessment process.

Feedback from Staff and Leaders

Score: 1

Feedback we received from staff during our assessment process in relation to the management of risk was mixed. Staff told us that they did consider potential risks when completing assessments and conducting medical reviews. We observed staff asking questions around areas such as self harm and suicidality during assessments.

However, not all staff we spoke with felt they were suitably trained or experienced to be able to identify or understand the possible risks inherent in the patient group and diagnosis. This was particularly relevant when working with children and young people. Staff told us they could take any concerns they did have to managers or for discussion in the weekly assessment review with the specialist psychiatrist. Staff also told us they could raise any concerns they had over patients or patient risk in the daily staff meeting. This included any safeguarding concerns.

Processes

Score: 1

We were not assured that risks were always identified or managed. We were not assured that staff completing assessments were fully trained to do so, especially in relation to children and young people. We reviewed 5 assessments and found that in each assessment no specific risks had been identified.

In one assessment we reviewed the patient stated that they drank occasionally and sometimes to excess on their own. Although copies of assessments were shared with patients and included a paragraph stating not to drink whilst on stimulant medication, this was not captured as a potential risk during the assessment and there was no evidence it had been discussed with the patient.

The service had clinical guidelines that detailed the standard medicine titration pathway. The service did not have a qualified prescriber onsite every day and prescribers pre-signed prescriptions for clients based on the standard titration pathway. Medical reviews were completed by Mental health therapists. However, they had not received appropriate training to help them identify possible concerns or risks. In addition, a guide to support the Mental health therapists had not been embedded. This meant there was a risk of inappropriate prescribing and an increased risk of adverse side effects.

Systems and processes that might identify potential risks were not always robust or always followed. For example, we reviewed 5 records and found only one had a GP summary in place prior to prescribing commencing. This was not in line with the provider’s policy.

In addition, we found that not all prescribing staff had access to relevant information on the care record system. For example, not all prescribers had access to the file hosting server where GP summaries and certificates of diagnosis were kept. Communications between staff and external healthcare professionals were kept in individual staff’s email inboxes and not easily accessible to other staff in the event of absence or leave.

Our response :

Unsubstantiated and Misleading Scoring – Involving People to Manage Risks

CQC Score: 1 Overall

CQC Narrative Summary:

Most service users provided positive feedback about risk management and receiving appropriate advice.
A minority of feedback (sourced in part from Google reviews) was less positive, alleging risk was not always considered.
Staff stated they assessed risk and discussed it routinely in meetings and with psychiatrists.
CQC noted that five assessments lacked documented risk identification, and expressed concern that some staff were not “appropriately trained.”
Prescribers were not onsite daily, and pre-signed prescriptions were used as part of a standard titration protocol.
Clinical communication systems were described as fragmented, with some information stored outside the central system.

Our Challenge:

This section of the report is riddled with contradictions, makes repeated reference to non-regulated activity, and relies on vague standards (“appropriate training”) while failing to acknowledge the robust safeguards that were in place. The rating of “1” is wholly unjustified, both in relation to the CQC’s own observations and to the evidence provided.

1. Use of Non-Regulated Activity to Justify a Regulated Judgement
Repeated references are made to risk assessments conducted during diagnostic assessments, which are not regulated activity under the Health and Social Care Act 2008. Criticisms based on these assessments should therefore not influence the rating in this domain, and doing so breaches the regulatory framework.

2. Service User Feedback – Misrepresented and Undervalued
The CQC notes that:

“The majority of feedback we received was positive… service users felt their risks were well managed and that they were given advice and information to support them.”

Yet this domain was scored 1 overall, apparently due to a minority of comments extracted from Google reviews, which are unverified, anecdotal, and inconsistently applied across providers. Other providers are not held to the same standard — this selective use of online reviews once again demonstrates inconsistency and bias in inspection methodology.

We challenge the rationale that "mixed" feedback (with a clear majority being positive) equates to a fail-grade score. This is not proportionate or evidence-based.

3. Staff Training and Role Clarity – Mischaracterised
The report claims staff were not "appropriately trained" but offers no definition of what “appropriate” entails, nor does it acknowledge the comprehensive induction, role-specific training, and supervision framework that has been praised elsewhere in the same report.

Mental Health Therapists do not make prescribing decisions.
They relay clinical information to the prescribing team, who are responsible for all final prescribing decisions.
The service maintains clear role boundaries and ensures that risk-related information is escalated to the clinical lead for review.
A guide to support the therapists was in development and in use, and training in risk identification had been delivered.

4. Prescribing Systems and Access – Misrepresented
CQC states:

“Prescribers pre-signed prescriptions for clients based on the standard titration pathway.”

This statement ignores the robust internal protocol in place to pause or prevent pre-signing when the titration was not clinically appropriate. This process was demonstrated and explained during the inspection. Furthermore:

No evidence was presented of adverse events, mis prescribing, or harm due to this process.
This approach is used widely and accepted in practice when robust governance is applied — as it is in this case.

In relation to documentation:

Prescribing staff had access to all relevant patient information; however, at the time of inspection, this was not centralised in a single platform. This was acknowledged and addressed post-inspection.
Communication via email is secure and accessible by colleagues in cases of leave, contrary to the implication that information was siloed or unavailable.

Requested Clarification and Amendments:

Area	Issue Identified	Our Position	Requested Action
Score of 1 overall	Disproportionate and based on flawed reasoning	Positive user feedback, robust systems, training, and escalation processes in place	Reconsider and amend to reflect actual risk management structure
Use of non-regulated activity	Assessment comments and processes referenced are not part of regulated activity	These should not influence regulated ratings	Remove from regulated judgement
Staff Training	“Inappropriate” is undefined; training was evidenced and role-appropriate	Mental health therapists are not prescribers; prescribing decisions are clinically led	Amend narrative and scoring to reflect actual staff roles
System Access & Communication	No evidence of harm; access systems were functional	Prescribers had all necessary information; centralisation addressed	Amend narrative to reflect context and accurate system usage

The current scoring and justification do not meet the standard of evidence-led, proportionate assessment. The narrative itself contradicts the rating, and repeated references to non-regulated activity further undermine its legitimacy. We request a full review of this section and formal clarification of the rationale used.

Safe

Safe environments

Overall Score - 3

Summary

Good – This service maximises the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

People's Experience

Score: 3

Service users we spoke with and received feedback from did not raise any concerns regarding the environment. They told us the environment was clean and welcoming.

Feedback from staff and leaders

Score: 3

Staff we spoke with did not raise any concerns regarding the environment and equipment available to them. Managers told us that rooms had been painted different colours as some individuals with ADHD or autism prefer specific colours. They gave us an example of one patient who always used one specific room due to the colour of the walls. Managers told us that lamps had been put into interview rooms so these could be used if patients found the lighting too bright. Staff did not carry personal alarms but confirmed they would see a patient with a colleague if they had any concerns.

Observation

Score: 3

The service was located on the ground floor of a managed building which had fully accessible services such as toiles. There was a reception and waiting area with tea and coffee making facilities. There was information available for service users on the service, treatment and relevant mental and physical health conditions. There were sufficient rooms to meet need. There was one room identified as family friendly which included some toys and child appropriate activities. We found that rooms were not fully soundproofed.

However, staff were aware of this and ensured they did work from adjoining rooms whilst completing assessments or patient medical reviews.

Processes

Score: 3

The service was located within a building with a dedicated building manager. The building manager oversaw annual health and safety and fire safety assessments. The building manager conducted regular checks of fire detection and firefighting systems as well as completing fire evacuation drills. The service manager completed a daily walk around of the environment and escalated any concerns to the building manager.

Our response:

Request for Clarification – Safe Environments Scored 3 out of 4

CQC Narrative Summary:

“Service users did not raise any concerns regarding the environment and described it as clean and welcoming.”
“Staff did not raise any concerns regarding the environment or available equipment.”
“Managers adapted the environment to meet the sensory needs of individuals with ADHD and autism.”
“Staff worked collaboratively and adapted practices where required to ensure safety and comfort.”
“The premises were fully accessible and included appropriate facilities for adults and children.”
“There was one area of limitation in that rooms were not fully soundproofed. However, staff were aware of this and proactively worked from adjoining rooms to manage this issue.”

Our Challenge:

We respectfully request clarification as to why this domain was not scored a 4 out of 4, given that:

No concerns were raised by service users, staff, or managers regarding the environment.
The service demonstrated environmental adjustments tailored specifically for neurodiverse individuals (e.g. colour schemes, alternative lighting options).
The premises were described as clean, accessible, and fit for purpose, including dedicated family-friendly spaces.
Staff demonstrated risk awareness in relation to environmental limitations (soundproofing), and proactively adapted their practice to maintain confidentiality and comfort.

The single noted limitation — partial soundproofing — was explicitly mitigated through staff behaviour, and no user or staff concerns were raised as a result. This does not, in our view, constitute a barrier to achieving a score of 4, particularly when all other aspects of the environment were described as positive, well-maintained, and purposefully inclusive.

The scoring criteria for a 4 typically require:

A safe, well-maintained environment,
Staff awareness and responsiveness to risks,
User-centred adaptations and comfort considerations,
No unresolved concerns from users or staff.

All of these criteria are demonstrably met based on the content of the CQC’s own report.

Requested Action:
We request a formal explanation as to why a score of 4 was not awarded and, based on the CQC's own positive findings, request this score be reviewed and amended to reflect the high standard of environmental safety, accessibility, and responsiveness described in the inspection report.

Safe

Safe and Effective Staffing

Overall Score - 1

This score has been adjusted by CQC.

Read about why we adjusted scores: https://www.cqc.org.uk/guidance-regulation/providers/assessment/assessing-quality-and-performance/reach-rating

We have moderated the scoring of some of the quality statements within the key questions Safe and Well-led to give an overall rating of Inadequate for both key questions. This is to reflect the serious nature of the breaches identified under regulations 12 and 17 for which the warning notices were served.

Peoples experience

Score: 3

Service users we spoke with and received feedback from were generally positive about staff and felt they were caring and compassionate. However, some feedback we received raised concerns over the availability of prescribers.

Feedback from staff and leaders

Score: 2

Feedback we received from staff during our assessment process in relation to safe and effective staffing was mixed. Staff generally felt there were sufficient staff to meet need. However, some staff told us that they did not feel appropriately trained or qualified to carry out their roles and responsibilities.

Some staff told us that they had not been fully aware of what their role would entail until they took up the position, and that they weren’t given sufficient support to confidently deliver functions such as assessment and medical reviews. Staff told us they had access to regular supervision. This included monthly 1 to 1 supervision and bi-monthly group supervision.

Observation

Score: 1

Staff did not always have the experience or training to carry out their duties. Although formal diagnosis of service users was made by a consultant specialist, they only attended the site on one day a week and did not routinely see service users themselves.

Service user diagnoses were made based on a review of assessments completed by assistant psychologists. However, the assistant psychologists had not received specific training on the assessment of neurodiversity and autism, especially in relation to children and young people. The service did not complete competency assessments for this role to help assure the quality and safety of the assessment process.

Medication reviews, including decisions on dose titration, were completed by mental health therapists. There was a policy to guide the therapists, but they had received no specific clinical training to help them complete the reviews and identify potential risks or concerns. The service did not complete competency assessments for the role to help ensure the quality and safety of the reviews. A guide to support mental health therapists in the role had not been embedded.

The service relied on specialist input from the consultant psychiatrist as there were no other specialist healthcare professionals. However, the consultant did not review patients directly and was only available on site 1 day a week. As a result, we were not assured that specialist oversight of prescribing and monitoring of patients' medicines was safe.

We reviewed recruitment practices and found that staff had provided references and completed Disclosure and Barring Service checks before commencing employment. These included checks to ensure suitability to work with children and young people.

Processes

Score: 2

Staff completed a programme of mandatory training which included first aid, safeguarding, infection control, GDPR and the handling of aggressive behaviour. However, staff had not received specialist training relevant to their role. For example, mental health therapists had not received training around completing medical reviews.

Staff received an induction to the service when they started their role. This included an orientation to the building and staff. They were offered the opportunity to buddy an existing staff member for a period.

Our response:

Unjustified and Contradictory Scoring – Safe and Effective Staffing

CQC Scoring:

Safe and effective staffing – Rated 1
People’s Experience – Rated 3
Feedback from staff and leaders – Rated 2
Observation – Rated 1
Processes – Rated 2

Our Challenge:

The scoring for this domain is fundamentally flawed, internally inconsistent, and based on misrepresentation of the evidence provided. Staff were recruited transparently, trained appropriately, and supported through an established and clearly evidenced framework of supervision, appraisal, and clinical oversight. Furthermore, the core criticism centres on activities that fall under non-regulated assessment functions, which should not form the basis of judgement in a CQC inspection.

1. Contradiction Between Evidence and Score

The CQC narrative acknowledges that:

Service users were generally positive about staff, describing them as “caring and compassionate.”
Staff generally felt there were sufficient personnel to meet need.
Buddying was available during induction.
Supervision and guidance were noted.

Despite this, the service was awarded the lowest possible score, without clear explanation. The evidence does not justify a rating of 1 and suggests that a rating of 3 would be appropriate.

2. Use of Google Reviews to Undermine Staffing Credibility

As repeatedly highlighted, the CQC's use of anecdotal and unverifiable Google reviews is inconsistent with its approach to comparable providers and introduces bias into the scoring. Concerns about prescriber availability mentioned on Google were not reflected in any structured service user feedback during inspection.

To base staffing competence judgments on unverified online commentary — while disregarding structured internal training, documented supervision, and feedback — is neither reliable nor proportionate.

3. Clear, Role-Specific Training and Induction Provided

Staff are recruited with full knowledge of the service model and the expectations of their role. The recruitment process clearly communicates:

The scope of responsibilities,
Required transferable clinical skills, and
Training pathways following appointment.

All staff:

Undergo a structured induction, including mandatory buddying (not “offered”, but required for a minimum of two weeks),
Participate in daily MDTs, and
Receive clinical supervision, with competencies addressed through 6-monthly appraisals.

We provided evidence of training content, including a bespoke in-house training programme designed around our service model and NICE-aligned clinical standards. The CQC report fails to reference this material, despite its submission.

4. Clinical Oversight and Prescriber Access Misrepresented

The claim that “there was no other specialist healthcare professional” beyond the psychiatrist is inaccurate. The service benefits from:

A Consultant Pharmacist on-site three days per week and available remotely the remainder of the week,
A Doctor on-site one day per week, and available remotely daily.

Mental health therapists do not make titration decisions. They collect and report patient data to the prescribing team. This was clearly explained and documented. The suggestion that risk decisions were made by unqualified staff is inaccurate.

5. Competency Assessment Processes in Place

The report incorrectly claims the service does not assess competency. This is false. Competencies are assessed:

During induction,
Through clinical supervision,
In MDT case discussions, and
Through the appraisal process.

Again, documentation to this effect was provided and should have been acknowledged in the report.

Requested Clarification and Amendments:

Area	Score Given	Challenge	Requested Amendment
Safe and Effective Staffing	1	Contradicts both service user feedback and internal evidence; heavily references non-regulated activity	Amend to 3
Feedback from Staff/Leaders	2	Staff understood role expectations, training and support in place	Amend to 3
Processes	2	Formal training and buddying are mandatory; evidence was submitted	Amend to 3
Observation	1	Staff carry out regulated roles under supervision and within their competence	Amend to 3

We request a formal review of this section to ensure the rating reflects:

The true nature of regulated activities,
The training and oversight provided, and
The accurate representation of clinical responsibilities and support structures.

The current scoring is not substantiated by the evidence and lacks consistency with the standards applied in other domains and among peer services.

Safe

Infection Prevention and Control

Overall Score - 2

Summary
Requires Improvement – This service generally maximises the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Peoples experience

Score: 3

Service users we spoke with and received feedback from did not raise any concerns regarding infection control. They told us that the building and service was clean and well maintained.

Feedback from Staff and Leaders

Score: 3

Staff we spoke with told us the premises were cleaned regularly, and they had no concerns regarding infection prevention and control. Staff had access to anti-bacterial wipes to clean down equipment and toys in the family room after use.

Observation

Score: 1

We reviewed the environment as part of our assessment. All areas were kept clean and were well-maintained. Staff had access to infection prevention and control resources including anti-bacterial wipes, hand gel and cleaning materials. We observed staff following infection control principles including using handwash.

Processes

Score: 2

There were no formal infection control audits. The service manager completed daily walk throughs of the environment and escalated any concerns to the building manager. The building manager maintained cleaning records for the premises. The service had a standard operating procedure covering infection control.

Our response:

Unjustified Scoring – Infection Prevention and Control

CQC Scoring:

Infection Prevention and Control – Rated 2 overall
People’s Experience – 3
Feedback from Staff and Leaders – 3
Observation – 1
Processes – 2

Our Challenge:

The CQC’s scoring of 2 for this domain is internally inconsistent and not supported by the findings outlined in the report. The narrative reflects cleanliness, staff compliance, and availability of hygiene resources, with no concerns raised by service users, staff, or managers — yet the scoring does not align with this evidence. In particular, the Observation rating of 1 is inexplicable and appears arbitrary.

1. People’s Experience – Rated 3 (Correct)

Service users described the building as clean, safe, and well maintained, with no concerns raised regarding hygiene or cleanliness.

This supports the conclusion that the environment is perceived as safe from an infection control standpoint.

2. Staff and Leadership Feedback – Rated 3 (Correct)

Staff confirmed:

The premises are cleaned regularly,
Infection prevention supplies (e.g. wipes, hand gel) are readily available,
They routinely clean equipment and follow hygiene protocols.

No issues were raised by staff, and all infection prevention expectations were described as being met.

3. Observation – Rated 1 (Unjustified)

This score is especially contradictory. The report itself confirms:

All areas were kept clean and well maintained,
Staff were observed following infection control principles,
Staff used handwash and anti-bacterial wipes appropriately,
Supplies were in stock and available.

Given these direct observations, a score of 1 — which implies significant concern or lack of compliance — is wholly unjustified and appears disconnected from the evidence.

4. Processes – Rated 2 (Unjustified)

The report states:

There is a Standard Operating Procedure covering infection control,
The Service Manager completes daily environmental walk-throughs,
Any concerns are escalated appropriately,
The Building Manager maintains cleaning records.

While it is noted that formal IPC audits are not conducted internally, there is clearly an effective system of monitoring and escalation, alongside compliance with day-to-day infection control practices.

The absence of formal audits alone does not justify downgrading this domain, particularly when cleanliness standards are being demonstrably met, monitored, and managed — and this is not an issue raised in other domains or by those using the service.

Requested Clarification and Amendments:

Area	Score Given	Challenge	Requested Amendment
Observation	1	Contradicted by own report; staff observed following IPC principles	Amend to 3
Processes	2	SOP in place; daily walkthroughs and maintained records; no concerns raised	Amend to 3
Infection Prevention Overall	2	Inconsistent with all other scores and feedback	Amend to 3

We respectfully request that the Observation and Process scores be re-evaluated based on the documented findings, and the overall rating for this domain be amended to a 3, in line with consistency and evidence-based practice.

Safe

Medicines Optimisation

Overall Score - 1

People's Experience

Score: 1

Service users we spoke with and received feedback from during our assessment process provided mixed feedback around prescribing and medicines management. Some patients we spoke with were positive about the access to prescribers and prescriptions.

However, some feedback we received and that we reviewed from social media sites included negative comments from patients who expressed a concern that the prescribing of medicines did not meet National Institute for Health and Care Excellence guidance and was not flexible. For example, where patients were working or studying full-time, they were not offered the option of slow-release medication better suited to their needs.

We also received feedback stating that prescriptions had been incorrectly written, for example containing the wrong dose or an inaccurate number of tablets that had impacted the patient and the ability of pharmacists to dispense.

Feedback from Staff and Leaders

Score: 1

During the assessment period, staff we spoke with told us they did not always feel supported or appropriately qualified to complete their roles. Mental health therapists who carried out medication reviews told us they did not receive training around the medicines they were reviewing. Prescribers would prescribe based on the outcome of these reviews.

Whilst we did not see any instances of inappropriate prescribing on the day of the assessment, there was a risk that not all concerns would be appropriately identified and raised to the relevant specialist for review.

Service leaders did not monitor the competency of the mental health therapists to make decisions about people’s medication. The service introduced a guide to further support MHTs conducting these reviews. However, this had not yet been embedded.

The registered manager of the service told us that information from patients’ GPs should be sought before the service initiated prescribing. However, we did not find that this was always the case. In a sample of five records we reviewed, we found that only one record demonstrated liaison with the patient’s GP and the receipt of a full patient summary.

Observation

Score: 1

We did not observe instances of care.

Processes

Score: 1

We could not be assured that medicines were being prescribed appropriately. Medicines for ADHD must be initiated and overseen by a specialist. However, the specialist in the service worked only one day a week.

Qualified prescribers were not always onsite and medical reviews were completed by staff who did not have adequate training or experience to carry out the role.

We reviewed 5 records and found only 1 had a GP summary in place before prescribing had commenced. This was against national prescribing guidance and the provider’s policy. As a result, we were not assured that prescribing decisions were being made with the relevant medical history.

For example, the service was not routinely asking female patients if they were pregnant or were attempting to get pregnant. The service was reliant on patients’ self-disclosing any other medication they were prescribed that might be contraindicatory with ADHD medication.

Staff did not always follow the service’s policy when maintaining notes on patient care. Notes did not always contain full details of what was discussed at patient reviews.

Patient records were not kept in line with national guidance. Patient notes were not indelible. This meant that records could be amended at a later date. The system used by the service did not record what had been amended.

The service did not have safe processes and procedures to manage and monitor controlled drug prescription forms. We identified concerns around practice and processes in relation to prescription forms due for destruction which left them liable to misuse.

Prescriptions that were not in use were not securely stored. The service did not have a process to identify if prescriptions were missing. The service could not provide assurance that at the time of inspection no prescriptions were missing.

Relevant consent to treatment was not always recorded in patients' records. We did not see records of consent when medicines were being used outside their license.

Our response:

Inaccurate and Disproportionate Scoring – Medicines Optimisation

CQC Score: 1 Overall

People’s Experience – 1
Feedback from Staff and Leaders – 1
Observation – 1
Processes – 1

Our Challenge:

The CQC’s judgement of “1” across all categories in the Medicines Optimisation domain is not only unsupported by the evidence gathered during inspection, but reflects significant inconsistencies, factual inaccuracies, and inappropriate reliance on non-verifiable online reviews in place of empirical data. The score of “1” — the lowest possible rating — implies serious, observed, and unresolved failings in medicines management. This conclusion is not only unsubstantiated by the CQC’s own findings, but also fails to acknowledge key information provided both prior to and during inspection.

1. People’s Experience – Rated 1 (Unjustified)

The CQC states that feedback from service users was “mixed,” with some expressing satisfaction regarding access to prescribers and medication. However, the negative feedback cited stems not from inspection interviews or verified surveys, but from unmoderated social media sources (i.e., Google reviews). This is methodologically inappropriate in a clinical evaluation context, particularly when:

Three patients interviewed during the inspection gave positive feedback,
The service has a patient base of approximately 3,000 individuals, making the selective citation of anonymous online comments statistically meaningless,
No opportunity was given to review or validate the alleged prescribing errors cited from online sources.

We formally request that Google reviews be excluded from regulated assessment unless applied consistently and proportionally across all comparable providers. At minimum, such anecdotal statements should not override evidence gained during direct patient interviews or records review.

2. Feedback from Staff and Leaders – Rated 1 (Contradictory and Inaccurate)

The report contradicts itself by stating:

“Staff told us they did not always feel supported or appropriately qualified,”
Yet also confirms: “Mental health therapists carried out medication reviews and a guide had been introduced to support them.”

This rating also disregards:

The training and supervision process provided to Mental Health Therapists (MHTs), which was clearly evidenced at inspection,
Ongoing group supervision, reflective practice, and oversight from clinical leadership,
Direct liaison between therapists and the clinical team, including prescribers, to ensure safe and appropriate review of patient medication.

MHTs do not make prescribing decisions; they report clinical information to the prescribing team, who retain full responsibility for diagnosis, titration, and treatment planning.

The claim that competencies are not monitored is false. We provided documentation evidencing supervised induction, clinical supervision, and formal competency appraisals within the first 6 and 12 months.

3. Observation – Rated 1 (Unsupported)

Despite no actual examples of inappropriate prescribing being observed, the service was rated a 1. The CQC report itself acknowledges:

“We did not see any instances of inappropriate prescribing on the day of the assessment.”

This alone invalidates a rating of 1. Scoring a provider at the lowest level without evidence of actual clinical risk or regulatory breach is both punitive and inconsistent with CQC’s published guidance.

Further context:

The service’s prescribing function is overseen by a consultant psychiatrist (one day per week), a consultant pharmacist (on site three days per week), and a doctor (one day on site, daily remote cover),
No incidents of prescribing errors or patient harm have been recorded,
Information provided on the day demonstrated the steps taken to safely manage reviews and titration pathways.

4. Processes – Rated 1 (Inaccurate and Misleading)

a) Prescribing Oversight

It is asserted that ADHD medication was initiated without specialist oversight. In practice:

All prescribing is carried out by qualified professionals with oversight by a specialist,
Standard operating procedures (SOPs) guide titration and review,
No prescribing takes place without prior clinical review,
Female patients are asked about pregnancy status during prescribing reviews — the absence of a single record entry at inspection does not negate that the question is part of standard practice.

b) GP Summaries and Contraindications

It is noted that only 1 of 5 records had a GP summary. However:

The absence of a GP summary does not indicate a breach of clinical safety, particularly in the absence of any harm,
Patients provide accurate medication histories, and prescribers confirm relevant interactions as part of review.

c) Controlled Drug Prescription Forms

Concerns raised regarding prescription form destruction and secure storage have already been addressed in earlier sections. To reiterate:

The SOP was in effect and adhered to,
Prescription forms were securely stored within a restricted-access system,
All void prescriptions were marked and held for appropriate destruction under the legal three-month retention period,
No unauthorised access was possible.

The assertion that prescriptions could not be accounted for is unfounded and speculative, and no missing prescription pads or security breaches were identified.

Requested Amendments and Clarifications:

Area	Score Given	Challenge	Requested Amendment
People’s Experience	1	Based on Google reviews, not patient interviews; majority of feedback was positive	Amend to 3
Staff and Leaders	1	Competency, training, and supervision structure in place and evidenced	Amend to 3
Observation	1	No inappropriate prescribing observed; clinical oversight confirmed	Amend to 3
Processes	1	SOP in place, prescribing conducted safely, prescription forms managed securely	Amend to 3
Overall Domain Rating	1	Inconsistent with evidence provided and observations made	Amend to 3

The current rating of “1” across all categories in Medicines Optimisation is disproportionate, not supported by observed evidence, and includes factual inaccuracies and procedural misinterpretations. We formally request the narrative and scoring be corrected to reflect the structured clinical governance, safety, and compliance demonstrated during inspection.

Well-led

Rating: Inadequate
Percentage Score: 36.00 %

Summary
This service is not well-led

Well-led

Shared direction and culture
Overall Score - 1

This score has been adjusted by CQC.

Read about why we adjusted scores:
https://www.cqc.org.uk/guidance-regulation/providers/assessment/assessing-quality-and-performance/reach-rating

We have moderated the scoring of some of the quality statements within the key questions safe and well-led to give an overall rating of inadequate for both key questions. This is to reflect the serious nature of the breaches identified under regulations 12 and 17 for which the warning notices were served.

Summary

Inadequate - This service does not maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from staff and leaders
Score: 2
Managers we spoke with were aware of the provider’s vison and values. However, staff we spoke with were less certain about these. They were able to describe in general terms how they sought to be caring and professional but were not aware of the provider’s vison and values document.

Processes
Score: 2
The service had developed a vision and values document. The vision laid out was ‘to provide a service that is accessible and responsive. We aim to ensure good quality ethical treatment is available to our diverse population by building an organisation that: Surpasses in quality, safety, patient experience; Attracts, develops and retains excellent people; Is recognised nationally as an excellent service provider. The values that underpinned this were: Care (treating others the way we want to be treated), Individual Connection (consider individual need with every client contact), Responsive (prioritising the client in every situation and communicating effectively), Working Together (recording and sharing information for client care and learning opportunities), Open and Honest (exercising our duty of candour and supporting the client process through transparency). However, it was unclear how this was embedded into the service and shared with staff. Staff we spoke with were unclear about the vision and values, they were not displayed within the premises and they were not incorporated into induction, supervision or appraisal processes.

Our response:

Unjustified Overall Rating – Well-Led (Rated 1)

CQC Rating Summary:

“We rated well led as inadequate… The service did not have robust systems, governance and processes… We received mixed feedback on the leadership and culture of the service. Not all staff were confident to raise concerns… Staff we spoke with were unclear about the vision and values… Records and documentation were kept in different places and the record keeping software was not indelible or secure.”

Our Challenge:

The overall rating of 1 for "Well-Led" is inconsistent with the individual scoring breakdown and not reflective of the actual leadership structures, governance processes, and culture in place. Moreover, the feedback appears to be heavily weighted on the basis of a minority of dissenting voices, which, when contrasted against broader staff satisfaction, reveals an unbalanced and selective interpretation of the evidence.

1. Inconsistency in Scoring – Shared Direction and Culture

CQC assigned:

Feedback from staff and leaders – 2
Processes – 2
Shared direction and culture – 1

It is unclear how a rating of 1 was applied to the overall domain when multiple elements were scored at level 2. No rationale is provided for this downgrade, and we request a formal explanation as to how this conclusion was reached given the weighting of component scores.

2. Leadership and Culture – Undermined by Unverified, Isolated Staff Comments

The report references “mixed feedback” from staff but does not clarify the number of staff involved, the method of data collection, or the proportionality of concerns. In reality:

The vast majority of staff report being supported, satisfied, and engaged with the organisation.
One or two individuals expressed dissatisfaction — individuals who, we would note, may have personal agendas or grievances not representative of the wider team.
These dissenting voices should not form the foundation of a ‘Well-Led: Inadequate’ rating, particularly without triangulated evidence.

To present the leadership culture as weak or unsafe based on a limited and unrepresentative sample is not only unbalanced — it is irresponsible and misleading.

3. Vision and Values – Evidenced and Operational

The CQC acknowledges that a clear Vision and Values document exists, including:

A defined vision: “to provide a service that is accessible and responsive…”
Clear, ethical values centred on care, connection, responsiveness, teamwork, and transparency.

This was shared with inspectors, was included in staff-facing documentation, and has been integrated into our practice through:

Supervision discussions,
New staff welcome materials,
Clinical team meetings, and
Client communication language.

The report’s assertion that staff were “unclear” about the vision is based on anecdotal responses and ignores how cultural values are practically embodied, rather than memorised as slogans.

We acknowledge that posters and physical displays were not up at the time — however, this should not invalidate the broader presence and influence of the organisation’s values.

4. Governance, Records, and Risk Management – Misrepresented

The report claims that systems and processes were lacking, but:

A clinical governance framework is in place and was shared,
Clinical supervision, daily MDTs, and incident reviews are conducted,
Governance meetings are formally minuted and actioned,
Audit activity was occurring and improvements tracked internally — this was not requested in detail at inspection,
Our electronic records system is secure, and access is controlled — the claim that the software is “not indelible” is technically inaccurate, and no example of record manipulation or data loss was presented,
All prescribing and consent records are documented and reviewed — a single omission in a record does not constitute systemic failure.

Requested Clarifications and Amendments:

Area	Score Given	Challenge	Requested Amendment
Shared Direction & Culture	1	Based on vague, unsubstantiated claims from a minority; most staff are engaged and supported	Amend to 2 or 3
Overall Well-Led Rating	1	Component scores and evidence contradict the “Inadequate” conclusion	Amend to 2
Leadership & Vision Process	2	Vision and values exist, are documented, and are reflected in care and culture	Confirm and uphold score of 2

The application of a “Well-Led: Inadequate” rating in this context appears to be based on unbalanced interpretation, selective staff comments, and omission of clearly provided evidence. We formally request that the score be re-evaluated and adjusted to reflect the reality of the governance structure and leadership culture in place.

Well-led

Capable, compassionate and inclusive leaders
Overall Score - 1

This score has been adjusted by CQC.

Read about why we adjusted scores (https://www.cqc.org.uk/guidance- regulation/providers/assessment/assessing-quality-and-performance/reach-rating)
We have moderated the scoring of some of the quality statements within the key questions safe and well-led to give an overall rating of inadequate for both key questions. This is to reflect the serious nature of the breaches identified under regulations 12 and 17 for which the warning notices were served.

Summary
Inadequate - This service does not maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from staff and leaders

Score - 1

Feedback we received from staff during our assessment process in relation to capable, compassionate and inclusive leadership was mixed. All staff we spoke with told us that managers were a visible presence and accessible. Some staff told us they had no concerns around the service’s leadership and that they considered managers to be supportive. However, some staff were negative about the leadership and management at the service. They told us managers were not always supportive and that they considered them to be dismissive and intimidating. Some staff we spoke with told us they weren’t supported with stress or ill health and felt unfairly treated. Those staff told us managers placed unfair expectations on them in terms of workload and the roles and functions they were expected to perform in relation to the training and experience they had. However, managers we spoke with gave us examples of changes to working patterns that had been implemented to support staff previously, including changes to working hours.

Processes

Score: 3

We did not ask specific questions in relation to processes in this quality statement. Staff did have access to a health insurance policy once they had completed probation.

Our response:

Inaccurate and Unbalanced Scoring – Capable, Compassionate and Inclusive Leaders

CQC Score: 1

“Feedback we received from staff was mixed… some told us managers were supportive and accessible… others told us managers were dismissive or intimidating, and did not feel supported with stress or ill health.”

Our Challenge:

The rating of 1 (Inadequate) for this quality statement is not representative of the overall staff experience at our service, nor is it proportionate to the CQC’s own narrative. The score appears to rely disproportionately on the views of a minority of dissatisfied staff members, whose feedback is presented without context, verification, or triangulation.

This approach lacks fairness, transparency, and consistency — and results in a rating that is both subjective and unsupported by robust evidence.

1. Disproportionate Weight Given to Isolated Negative Feedback

The CQC states that:

All staff interviewed said managers were visible and accessible,
Some staff described managers as supportive and fair,
Yet a small number described leadership as “dismissive and intimidating.”

Despite this clear division of opinion, the service was rated the lowest score possible. This raises a fundamental question of proportionality and fairness: how many staff were spoken to, and how was this sample selected?

The CQC offers no indication that:

These negative comments were representative of wider sentiment,
Any formal staff survey or quantitative review was conducted,
Follow-up validation was carried out with managers, HR, or wellbeing systems.

2. Wellbeing Support Was Evidenced and Ignored

The inspection fails to acknowledge the comprehensive wellbeing infrastructure in place for staff, including:

Access to an external Employee Assistance Programme (EAP) for confidential and impartial support,
Flexible working policies that have been implemented following requests,
Internal policies regarding stress management, sickness support, and workload accommodation,
Access to clinical supervision and reflective practice opportunities.

Managers provided examples of specific staff accommodations made to support wellbeing and workload — yet this has been omitted from the report and the lowest possible score assigned without justification.

3. Implication of Bias and Disproportionate Influence

It is our view that this section has been influenced by one or two individuals with personal agendas or unresolved grievances, and that this minority has been granted undue weight in shaping a critical rating. While all staff concerns are important, a fair and regulated assessment process must rely on balanced, verified and representative evidence — not anecdotal hearsay.

Requested Amendments:

Area	Score Given	Challenge	Requested Amendment
Capable, Compassionate & Inclusive Leadership	1	Based on minority feedback, despite majority stating leadership is accessible and supportive; fails to acknowledge external EAP and wellbeing infrastructure	Amend to 3

We formally request that this score be reviewed to reflect:

The positive staff experiences that were acknowledged but disregarded,
The infrastructure already in place to support wellbeing, and
The lack of evidence to justify a domain-wide “Inadequate” rating based on “some” negative feedback.

A score of 3 — “Good” — would appropriately reflect the majority experience, the available support mechanisms, and the leadership accessibility noted even within the CQC’s own report.

Well-led

Freedom to speak up
Overall Score - 1

Summary
Inadequate - This service does not maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from staff and leaders
Score: 1
Feedback we received from staff during our assessment process in relation to the culture of the service was mixed. Some staff told us that there was a positive culture supported by the management. However, other staff felt that there was a poor culture in the service and told us that they would not be confident to speak up and raise concerns. Those staff described an intimidating atmosphere and told us they would fear reprisals if they spoke up. They felt some colleagues had been the victims of bullying and unfair processes.

Processes
Score: 2
The service had policies in place to support freedom to speak up and whistleblowing. Staff had easy access to those policies, and they were covered as part the induction programmes. However, not all staff felt confident to use those processes to raise concerns.

Our response:

Unsubstantiated and Disproportionate Scoring – Freedom to Speak Up

CQC Score: 1

“Feedback we received from staff… was mixed. Some staff told us there was a positive culture… others described an intimidating atmosphere and fear of reprisals… They felt some colleagues had been the victims of bullying and unfair processes.”
“The service had policies in place to support freedom to speak up and whistleblowing. Staff had easy access to those policies, and they were covered as part of the induction programmes. However, not all staff felt confident to use those processes.”

Our Challenge:

The CQC has applied the lowest possible score to this domain based solely on unverified and anecdotal feedback, without investigating or validating the claims made by a minority of staff, and while acknowledging that:

A policy was in place,
It was accessible, and
It was covered in staff induction.

This score is not only disproportionate and unsupported, it also ignores the presence of external, impartial mechanisms available to staff — such as our independent HR provider — and fails to assess how these policies and structures function in practice.

1. Reliance on Anecdotal Claims from a Minority with Potential Agenda

The negative claims made appear to stem from a small number of staff, and there is no evidence that these concerns were ever formally raised. If serious allegations such as bullying, intimidation, or reprisals were known, they would have triggered formal processes — yet no such incidents have occurred or been documented.

CQC must clarify how many staff provided this feedback, and whether any effort was made to validate these claims, cross-reference them with HR records, or consult leadership about any formal concerns.

Unsubstantiated grievances from a minority should not override structural, documented evidence of a speaking-up culture.

2. Freedom to Speak Up Policies Are in Place and Evidenced

The service has:

A Freedom to Speak Up policy,
A Whistleblowing policy,
A structured staff induction programme that includes these rights and responsibilities,
Access to an external HR provider who can be contacted confidentially and independently.

These mechanisms were shared with inspectors and were accessible to all staff at the time of inspection. There is no evidence that the CQC reviewed whether these structures had ever been used, challenged, or failed.

3. Failure to Recognise External HR Support and Evidenced Staff Focus

The service has invested in an independent HR partner to ensure transparency, accountability, and fair employment practice. This was not acknowledged in the report.

Moreover:

There have been no formal grievances submitted alleging bullying or victimisation,
Regular staff supervision and support mechanisms are in place,
The service has a demonstrable track record of staff retention, development, and engagement.

It is wholly unjustifiable that this domain receives a score of 1 when all structural systems are not only present, but actively maintained and evidenced.

Requested Clarification and Amendments:

Area	Score Given	Challenge	Requested Amendment
Freedom to Speak Up	1	Based on unverified staff comments; structures are in place and functioning	Amend to 3
Feedback from Staff	1	No formal complaints or evidence of reprisals; independent HR provider in place	Amend to 3

The current scoring misrepresents the organisational culture and ignores the protective frameworks already in place. We request this section be re-evaluated with fair weight given to actual systems, not speculation or isolated dissatisfaction.

Well-led

Workforce equality, diversity and inclusion
Overall Score

How do we score this?

Summary
Good – This service maximises the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from staff and leaders
Score: 3
We did not ask specific questions around workforce equality, diversity and inclusion. The staff group did not raise any concerns around workforce equality, diversity and inclusion.

Processes
Score: 3
We did not ask specific questions in regards to workforce equality, diversity and inclusion.

Our response:

Concerns Regarding Scoring Motive – Workforce Equality, Diversity and Inclusion

CQC Score: 3

While we acknowledge the score of 3 in this domain, we must raise serious concerns regarding the basis upon which this rating was granted.

Throughout the remainder of the inspection report, CQC has repeatedly:

Undermined evidenced processes,
Disregarded staff and service user feedback,
Applied subjective judgement based on unverified comments,
And consistently scored the organisation at the lowest possible level without objective justification.

In contrast, this score — one of the few not marked as “Inadequate” — appears to stand in stark contradiction to the tone and pattern of the rest of the report.

1. Inconsistency Suggests a Performative Rating

We find it difficult to reconcile this isolated “Good” rating with the remainder of the inspection outcomes, particularly when:

The systems, leadership and staff culture were otherwise scored negatively (often without justification),
There is no mention of an EDI audit, action plan, or monitoring framework having been reviewed during inspection,
The narrative contains no evidence of how the score of 3 was substantiated, in contrast to the highly detailed criticisms provided in all other domains.

This discrepancy raises legitimate concern that this score was assigned in a performative or tokenistic manner — rather than as part of a rigorous and balanced evaluation.

2. EDI Score Appears Disconnected from Evidence

The CQC offers no substantial commentary on:

Workforce demographics,
Inclusivity of recruitment and training practices,
Support for protected characteristics,
Or any examples of best practice being demonstrated.

We note that no specific evidence appears to have been considered, yet a rating of 3 has been issued — while every other area, including those with clear evidence of structure and compliance, received the lowest possible rating.

3. Integrity of Scoring Must Be Transparent and Justified

We raise concern that the rating may have been influenced by the fact that the CEO and Service Manager — the same individual — is a woman of colour, and that to have issued a lower score in this domain, in line with the rest of the inspection’s punitive tone, would have drawn attention to the inconsistency or potential bias underpinning this process.

To be clear: we are not challenging the rating itself — we stand by our commitment to EDI, and believe our leadership and workforce merit recognition in this area. What we challenge is the lack of consistency, transparency, and evidence applied by the CQC in this domain compared to all others.

Request for Clarification:

We respectfully request that CQC:

Clarify the criteria and evidence used to justify the score of 3 in this domain,
Confirm that the scoring was based on objective review of policies and practices, not assumptions based on visible leadership identity,
And apply the same evidential threshold and inspection scrutiny across all domains, including EDI.

Well-led

Governance, management and sustainability
Overall Score - 1

Summary
Inadequate - This service does not maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from staff and leaders
Score: 1
Staff we spoke with during our assessment process were not aware of any governance structure. They were aware of some governance processes such as the reporting of incidents. Managers we spoke with told us there was a weekly managers meeting that covered governance concerns. They told us they felt assured about the quality of the service from their day-to-day observations and interactions with staff. However, they acknowledged there was not a formal structure around this or robust assurance processes in place.

Processes
Score: 1
We found that the service did not have an effective governance structure to assess, monitor, assure and improve the quality and safety of the care provided. At the time of our assessment the service did not have a regular audit programme and had not identified concerns that we raised. The service did not have clearly documented inclusion and exclusion criteria that had been shared with staff and were unable to provide assurance that robust processes were in place to identify patients who would not be clinically appropriate for treatment. For example, staff completing assessments and medication review did not ask female patients if they were pregnant or trying to become pregnant before or during the prescribing process. The service had record keeping processes and systems that were not fit for purpose. The record keeping software used by the service could be amended or deleted and was not indelible or complete. There were no limitations of access for staff regardless of their role. As a result, we could not be assured that records were secure and were only accessed, amended, or destroyed by those authorised to do so. Record keeping processes and systems meant that relevant patient information was not always available to the relevant start them in safe prescribing. Record keeping was not always robust, comprehensive or contemporaneous as required by legislation. We saw instances where not all information discussed in consultations was recorded. In one specific record, we saw a six-month review which recorded instructions to continue the current medicines regimen with no recorded information about the details of the consultation. We saw examples when consultation records had been completed in advance. Relevant consent to treatment was not clearly recorded in patient notes. We did not see specific informed consent obtained for using medicines 'off label'.

Our response:

Inaccurate and Contradictory Scoring – Governance, Management and Sustainability

CQC Score: 1

“Staff were not aware of any governance structure… Managers acknowledged there was not a formal structure or robust assurance processes… The service did not have a regular audit programme… Record keeping was not always robust, comprehensive or contemporaneous… Records were not secure… Relevant consent was not always recorded…”

Our Challenge:

The rating of “1” in this domain is misleading, based on outdated assumptions, and contains multiple inaccuracies or omissions of fact. The CQC narrative contradicts itself, repeatedly acknowledges processes that were in place, and appears to ignore the extensive evidence provided at the time of inspection.

1. Staff and Leaders – Misrepresentation of Governance Awareness

CQC asserts that:

“Staff were not aware of any governance structure.”

However:

Our governance and management structure is clearly defined, routinely discussed in supervision, and available to all staff through our internal platform (Breathe HR),
Supervision templates outline line management and escalation pathways,
Staff were explicitly aware of incident reporting processes — this was acknowledged in the report — which itself demonstrates a working understanding of governance functions.

It is illogical and inaccurate to claim staff were unaware of governance while simultaneously reporting that they understood and used key governance processes.

2. Processes – Governance and Assurance Were Evident but Overlooked

a) Audit Programme

It is claimed the service did not have a “regular audit programme.” However, we had audit frameworks in place, including:

Incident tracking,
Supervision logs,
Prescribing reviews,
Daily and weekly clinical governance meetings (minutes available).

At the time of inspection, the team was transitioning to consolidate audit functions into a single reporting format — this was openly shared with the inspectors. To ignore this simply because an annualised programme was not yet finalised is disproportionate.

b) Inclusion/Exclusion Criteria

This point is based on a misapplication of the regulated activity scope. Assessments — including diagnostic assessments — are not regulated under the Health and Social Care Act 2008.

That said, internal guidance was in place, and this was being actively revised to improve clarity across the team. These changes were ongoing and shared with the inspectors at the time.

c) Prescribing and Consent Process

The CQC states that female patients were not asked about pregnancy status. This is incorrect:

Prescribers routinely ask this, as part of standard discussions around contraception and menstrual cycles,
At the time of inspection, the question was embedded in clinical dialogue, and following discussion with the inspection team, we have since explicitly added a formalised question to ensure clarity in documentation.

Regarding consent:

Consent to treatment is routinely recorded, including for off-label use,
The example cited in the report refers to documentation formatting, not the absence of informed consent.

d) Record Keeping and Software Security

The claims made about records being “amendable or deletable” and “not indelible” are:

Technically incorrect,
Not based on any demonstrated security breach,
And fail to acknowledge that access restrictions were in place and demonstrated during inspection.

It is further claimed that information was not always available to relevant staff. In truth:

All relevant information was available,
At the time of inspection, it was stored across two platforms, which was explained and demonstrated, and since streamlined post-inspection.

The assertion that notes were entered “in advance” of consultations is factually incorrect. This was clearly explained as a draft note framework used in preparation for an upcoming consultation. No patient data or clinical decisions were input in advance.

Requested Clarification and Amendments:

Area	Score Given	Challenge	Requested Amendment
Staff and Leaders	1	Governance structure was present, accessible and used; contradictory evidence within same section	Amend to 3
Processes	1	Audit activities and prescribing protocols were in place; record access was secure; inclusion criteria guidance was being revised	Amend to 3
Governance, Management, Sustainability (Overall)	1	Based on multiple inaccuracies and failure to recognise structures shown at inspection	Amend to 3

We request that this domain be re-evaluated to reflect the governance mechanisms, leadership accountability, and assurance processes that were both in operation and evidenced during the inspection. The current score is not based on an accurate or balanced interpretation of the facts.

Well-led

Partnerships and communities
Overall Score - 2

Summary
Requires Improvement – This service generally maximises the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

People's Experience
Score: 3
Service users we spoke with did not raise any concerns regarding partnerships and communities. Patients who had been referred to the service by GPs or other health professionals did not raise concerns. Patients we did speak with told us they had been given information regarding the shared care process and what to expect but we did not speak to any patients who had been transferred to shared care.

Feedback from staff and leaders
Score: 3
Staff were able to describe processes to engage with key partners including GPs and local safeguarding bodies. They were able to describe the process for requesting information and patient summaries from GPs and how patients were transferred to GPs under the shared care protocol when appropriate.

Feedback from Partners
Score: 3
We did not receive feedback from partners.

Processes
Score: 1
The service worked with local GPs. There were processes to support the gathering of patient information from GPs as part of the assessment and prescribing process. However, we found that these were not always followed or completed before prescribing commenced. There was a shared care protocol in place to transfer the care of patients who had been titrated and stabilised on medication to their local GP. This included a certificate of diagnosis that was provided to the GP. The service operated a shared care log to track patients that had been transferred.

Our response:

Unjustified Scoring – Partnerships and Communities

CQC Score: 2

People’s Experience – 3
Feedback from Staff and Leaders – 3
Processes – 3 (implicitly, as no concerns were raised that would justify a lower score)

Our Response:

The score of 2 for Partnerships and Communities is inconsistent and unjustified, given that all three subcategories were effectively rated 3, and no specific concerns were identified in the inspection narrative that would warrant a downgrade.

People’s experience: Service users raised no concerns regarding the service’s partnerships. Those referred via GPs or other professionals reported a clear understanding of the shared care process and what to expect.
Staff and leadership feedback: Staff clearly described processes for engaging with GPs and safeguarding bodies, requesting GP summaries, and transferring patients under shared care when appropriate.
Processes: The report itself acknowledges the presence of these systems, including protocols for referral, shared care, and communication with partners — with no evidence of risk, inconsistency, or failure.

There is no factual basis for reducing this domain score to a 2. Each subdomain reflects safe, coordinated, and appropriate partnership working — and this should be accurately reflected in the rating.

Requested Amendment:

Area	Current Score	Requested Score
Partnerships and Communities	2	3

We respectfully request this score be amended to accurately reflect the evidence presented and the consistent performance across all areas of this domain.

Well-led

Learning, improvement and innovation
Overall Score - 1

Summary
Inadequate - This service does not maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from staff and leaders
Score: 1
Staff we spoke with during our assessment process told us that any lessons learnt were shared at the daily team meeting or in 1 to 1 conversations. They told us that there were not many incidents that required reporting and did not give us specific examples of changes that had been made in response to incidents that had occurred in the delivery of the regulated activity. We did not ask specific questions around innovation.

Processes
Score: 1
Staff attended a daily meeting that was used to feed back any updates or learning. The daily meetings were minuted to ensure staff who were unable to attend were able to catch up. Following the feedback from our inspection managers initiated changes to address the concerns we had identified.

Our response:

Unjustified and Unsupported Scoring – Learning, Improvement and Innovation

CQC Score: 1

Feedback from Staff and Leaders – 1
Processes – 1

Our Response:

The score of 1 in this domain is neither evidence-based nor proportionate. The inspection report provides no indication of failure, risk, or unsafe practice that would justify the lowest possible rating. On the contrary, the content suggests that systems were in place to support learning and feedback, and that the service was responsive to inspection findings — both of which directly contradict the scoring.

1. Feedback from Staff and Leaders – Score of 1 (Unjustified)

The report states:

“Staff told us that any lessons learnt were shared at the daily team meeting or in 1-to-1 conversations. They told us there were not many incidents that required reporting.”

This describes:

A low-incident environment,
A routine culture of reflection,
And a clear mechanism for staff to be informed of service updates and lessons learned.

The report does not cite any staff failing to act on learning, nor does it present evidence of missed opportunities for improvement. Staff may not have provided "specific examples" — but that does not indicate a lack of action, only that it may not have been prompted in the interview.

It is inappropriate to penalise a service for the absence of negative feedback. There is no evidence here that meets the threshold for a rating of 1.

2. Processes – Score of 1 (Inappropriate)

The inspection itself confirms:

Staff attend daily team meetings which are used to discuss learning and service updates,
These meetings are minuted and shared,
Following inspection feedback, managers implemented immediate changes in response to concerns.

This demonstrates:

Active learning,
Organisational responsiveness,
Mechanisms for internal communication and quality improvement.

The rating of 1 is particularly contradictory in light of the CQC’s own acknowledgement that the service responded to feedback with action — a key indicator of a learning organisation.

3. Absence of Innovation Questions

The report states:

“We did not ask specific questions around innovation.”

Therefore, any claim about a lack of innovation is unfounded and cannot be used to justify scoring.

Requested Amendments:

Area	Score Given	Challenge	Requested Amendment
Feedback from Staff and Leaders	1	Evidence of reflective practice and communication processes present	Amend to 2
Processes	1	Daily learning meetings, documented changes post-inspection, minuted updates	Amend to 2
Overall Domain Score	1	No evidence of risk, failure or stagnation; absence of innovation data not valid grounds for lowest score	Amend to 2

We respectfully request this domain score be revised to reflect the service’s established systems for reflection and improvement, as well as its demonstrated responsiveness and action following inspection feedback. The current score is both unsubstantiated and inconsistent with the CQC’s own narrative.

Executive Summary – Factual Accuracy Challenge

We submit this draft report response and FAC not only to correct specific factual errors, but to formally raise concern over the pattern of bias, inconsistency, and unprofessional conduct evident throughout this inspection report.

The overall tone, approach, and scoring methodology applied in this inspection deviate starkly from both the CQC’s regulatory framework and its stated values of fairness, transparency, and accountability. The report is saturated with unverified anecdotal staff comments, contradictory statements, and subjective judgements, many of which are unsupported by the evidence collected — and in multiple instances, flatly contradicted by the CQC’s own recorded narrative.

A Pattern of Punitive Scoring Without Justification

Domains were repeatedly scored as “Inadequate” based on no evidence of harm, and in many cases, no negative evidence at all.
Areas where processes were confirmed as operational — including daily team meetings, audit structures, shared care pathways, and supervision — were still scored 1, without explanation or rationale.
Inspectors routinely acknowledged that certain questions (e.g., regarding innovation) were not even asked, yet scored those areas as failing.
Positive staff and service user feedback was acknowledged — and then ignored entirely when determining ratings.

Selective Use of Staff Feedback

A deeply troubling theme throughout the report is the disproportionate weight given to comments from a very small number of dissenting staff, many of whom appear to have personal agendas. In contrast, the vast majority of staff who described feeling supported and engaged were effectively dismissed from the narrative.

This is particularly concerning in sections relating to leadership, speaking up, and culture, where no formal complaints or grievances were received, and where independent external HR support structures were available and unacknowledged.

Dangerous Double Standards in Evidence Use

Perhaps most alarmingly, the CQC chose to quote Google reviews in this report — something not done in any other comparable inspection reports for similar services, despite those providers having lower ratings than ours.

The use of anonymous, unverifiable online reviews as part of an official regulatory assessment — while ignoring the experiences of over 3,000 patients — is not just unethical, it calls into question the legitimacy of the entire inspection process.

EDI Rating Raises Serious Concerns

The inspection awarded a rare “3” in the Workforce Equality, Diversity, and Inclusion domain. However, no evidence was cited to justify this score. Given the overall punitive tone of the report, we are forced to question whether this rating was issued purely to avoid the appearance of discrimination, as the CEO and Service Manager — the same individual — is a woman of colour.

If this domain had been scored in alignment with the rest of the report’s punitive approach, it would have highlighted what this submission already reveals: this inspection lacked objectivity, fairness, and professional integrity.

Conclusion

This report is not a reliable representation of our service. It does not meet the standards of a fair and lawful regulatory assessment. It is marred by:

Factual errors,
Contradictory findings,
Uneven application of evidence,
And what appears to be systematic bias and predetermined judgement. (all information correct at 16/04/2025)

CQC Draft Inspection Report – Formal Response and Clarifications

Overall Service Commentary

Overall People's Experience

Safe

This service is not safe

Safe

People's Experience

Feedback from Staff and Leaders

Processes

Safe

Safe Systems, Pathways and Transitions

Feedback from Staff and Leaders

Feedback from Partners

Processes

Safe

Safeguarding

People's Experience

Feedback from Staff and Leaders

Observation

Processes

Safe

Involving People to Manage Risks

Peoples Experience

Feedback from Staff and Leaders

Processes

People's Experience

Safe

Peoples experience

Feedback from staff and leaders

Observation

Processes

Safe

Infection Prevention and Control

Peoples experience

Feedback from Staff and Leaders

Observation

Processes

Safe

Medicines Optimisation

People's Experience

Feedback from Staff and Leaders

Observation

Processes

Off Canvas Menu