Welcome to Brightpath Neuro
Policies and Procedures

Brightpath Neuro Assessment is a private mental health service specializing in comprehensive assessments and tailored treatment plans for neurodevelopmental and mental health conditions. We provide expert support for: Autism (ASC) ADHD Dyslexia Common mental health disorders, including anxiety, depression, and sleep issues Our experienced team of professionals is committed to helping individuals understand their challenges and develop effective strategies to improve their well-being.

Bright Path Neuro is NOT a crisis service. If you are in crisis or need urgent support, please reach out to the appropriate services listed below:

🚨 Emergency Services (Immediate Danger)

Call 999 – If you are in immediate danger or need urgent medical attention. Go to your nearest A&E (Accident and Emergency) – If you require urgent medical care or are at risk of harming yourself or others.

📞 24/7 Crisis Support Helplines

Samaritans – Call 116 123 (free, open 24/7) For emotional support and someone to listen without judgment.

Shout – Text 85258 (free, open 24/7) For immediate support via text message.

Childline – Call 0800 1111 (free, open 24/7) For support if you are under 19.

National Suicide Prevention Helpline – Call 0800 689 5652 (open 24/7) For free and confidential support with thoughts of suicide.

🏥 Mental Health Crisis Teams

Contact your local NHS Mental Health Crisis Team – Find your local team by calling NHS 111 (open 24/7). If you are already under the care of a mental health team, contact them directly for advice and support.

💬 Non-Emergency Mental Health Support

Mind – Call 0300 123 3393 or text 86463

For mental health information and support (available 9 am – 6 pm, Monday to Friday).

CALM (Campaign Against Living Miserably) – Call 0800 58 58 58 (open 5 pm – midnight)

For support with mental health and suicidal thoughts.

If you need support but are not in immediate danger, please reach out to your GP or local mental health services.

Yes, our team consists of highly experienced and qualified healthcare professionals. Our Clinical Lead has over 30 years of experience in health and social care. He is an Advanced Mental Health Nurse Practitioner, a Fellow of the Society of Education and Training, and a Non-Medical Prescriber. All our staff are fully trained in: QB Test (for ADHD assessments) ADOS-2 and ADI-R (for autism assessments) Sleep and Weight Management We provide a holistic care package tailored to each individual's needs, combining expert knowledge with compassionate care.

Each service follows its own pathway, but we aim to provide you with an outcome within 24 hours after receiving the final piece of evidence. Our streamlined process ensures a quick turnaround without compromising the quality and depth of the assessment.

If medication is recommended as part of your treatment, a Signature RX prescription will be issued by our prescribing team. The prescription can be sent directly to your preferred pharmacy for collection or delivery. You'll receive clear instructions on how to take your medication, and our team will be available to support you with any questions or adjustments needed.

Your Rights at Brightpath Neuro At Brightpath Neuro, we are committed to protecting your rights and ensuring that you receive the highest standard of care. We recognise and respect your legal rights as a client, and we aim to provide a safe, supportive, and professional environment at all times. This document outlines your rights when using our services and how we protect and uphold those rights.

1. Your Right to Be Treated with Dignity and Respect You have the right to: Be treated with dignity, respect, and professionalism at all times. Be listened to without judgment or discrimination. Receive services in a safe, inclusive, and non-discriminatory environment. Be free from abuse, harassment, exploitation, and neglect.

2. Your Right to Confidentiality and Privacy You have the right to: Have your personal and medical information handled in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018. Request that information about you is not shared without your consent, unless there is a legal obligation or safeguarding concern. Access information about how your data is used, stored, and protected (see our Privacy Policy).

3. Your Right to Access Your Records You have the right to: Request a copy of your personal records or assessment reports. Have factual inaccuracies in your records corrected promptly. Request that non-essential information is removed from your records (subject to legal requirements). Receive a response to your request within 30 days (in line with UK GDPR).

4. Your Right to Make Decisions About Your Care You have the right to: Be involved in all decisions regarding your care and treatment. Give or withhold consent for treatment or services. Change your mind and withdraw consent at any time without consequence. Refuse any assessment, treatment, or recommendation (unless legally required). Appoint an advocate or representative to support you in making decisions.

5. Your Right to Be Informed You have the right to: Be informed about the nature, purpose, risks, and benefits of any service offered. Be provided with clear and accurate information about your diagnosis, treatment options, and next steps. Receive communication in a format that is accessible and understandable to you (e.g., large print, easy read). Ask questions and receive honest and timely answers.

6. Your Right to Complain or Appeal You have the right to: Make a complaint if you are dissatisfied with any aspect of your care or service. Appeal a diagnosis or clinical decision if you disagree with the outcome (see our Diagnosis Appeal Policy). Have your complaint or appeal handled fairly, confidentially, and without fear of retaliation. Escalate your complaint to an independent authority if you remain dissatisfied (e.g., Care Quality Commission (CQC)).

7. Your Right to Access and Equality You have the right to: Access Brightpath Neuro’s services regardless of age, gender, race, ethnicity, disability, sexual orientation, or religious belief. Request reasonable adjustments to accommodate any disability or specific need. Have your cultural and religious values respected in your care. Be supported in your preferred language or communication style, where possible.

8. Your Right to Be Safe and Protected You have the right to: Receive services in a safe and supportive environment. Be protected from harm, abuse, neglect, or exploitation. Report any concerns about your safety to Brightpath Neuro without fear of reprisal. Have your safeguarding concerns investigated and acted upon promptly.

9. Your Right to Withdraw from Services You have the right to: Withdraw from any service at any time without consequence (unless legally required). Request a transfer of your care to another provider if you wish to change service providers. Refuse any involvement in research, training, or observation without affecting your care.

10. Your Right to Support and Advocacy You have the right to: Appoint an advocate, family member, or legal representative to support you in making decisions. Request an independent advocate if you feel unable to express your views effectively. Be supported by someone you trust during assessments, meetings, and consultations. Be informed of local advocacy and support services available to you.

11. Your Right to Non-Discrimination You have the right to receive services without discrimination on the grounds of: Age Disability Gender identity Sexual orientation Race or ethnicity Religion or belief Marital or civil partnership status Pregnancy or maternity Socioeconomic background

12. Your Right to Continuity of Care You have the right to: Receive consistent and continuous care from Brightpath Neuro. Be informed of any changes to your care plan or diagnosis. Request a second opinion if you are unsure about a diagnosis or treatment recommendation. Have access to follow-up care or reviews if needed.

13. Your Right to Feedback and Improvement You have the right to: Provide feedback on your experience with Brightpath Neuro. Suggest improvements to services without fear of retaliation. Have your feedback acknowledged and acted upon where possible. Receive a response to any formal feedback within 10 business days.

14. How We Protect Your Rights Brightpath Neuro is committed to upholding your rights by: Providing all staff with training on client rights, equality, and diversity. Monitoring service delivery to ensure compliance with client rights and legal standards. Investigating any reports of rights violations and taking corrective action where necessary. Seeking feedback from clients to improve the quality and accessibility of our services.

15. How to Exercise Your Rights If you wish to exercise any of your rights or need further information, you can contact us directly: Email: [email protected]

Terms and Conditions

1. Introduction Welcome to Brightpath Neuro. These Terms and Conditions ("Terms") govern your use of our services, website, and products. By accessing or using our services, you agree to be bound by these Terms. If you do not agree to these Terms, please do not use our services.

2. Definitions "We", "Us", "Our" – Refers to Brightpath Neuro. "You", "Your" – Refers to the customer, client, or user of our services. "Services" – Refers to all assessments, consultations, and support services provided by Brightpath Neuro.

3. Services We provide professional neurodiversity and mental health assessments and support, including but not limited to: ADHD, Autism (ASC), and Dyslexia Assessments Sleep Assessments Weight Management Services Mood and Mental Health Support All services are provided by qualified professionals and are tailored to individual needs. We reserve the right to modify or withdraw any of our services without prior notice.

4. Payment Terms Full payment is required at the time of booking unless otherwise agreed. Payments are processed securely via our online payment system. Failure to make payment may result in the cancellation of your booking. Refunds are available only under specific circumstances (see Section 6).

5. Cancellations and Rescheduling Cancellations made more than 48 hours before an appointment are eligible for rescheduling or a full refund. Cancellations made within 48 hours of an appointment may be subject to a cancellation fee of up to 50% of the service fee. Failure to attend an appointment without prior notice will result in a full charge for the service.

6. Refund Policy Refunds are only offered if: The service is cancelled by Brightpath Neuro. The service is not delivered as described due to an error on our part. A medical or personal emergency prevents you from attending, and evidence is provided.

7. User Obligations By using our services, you agree to: Provide accurate and complete information when booking and during assessments. Follow professional advice and recommendations to the best of your ability. Treat our staff with respect and professionalism.

8. Data Protection and Privacy Your personal information is processed according to our Privacy Policy. We are committed to protecting your personal data and only use it for the purpose of providing and improving our services.

9. Limitation of Liability Brightpath Neuro is not liable for any indirect or consequential loss resulting from the use of our services. Our total liability for any claim arising out of these Terms is limited to the amount paid for the service.

10. Governing Law These Terms are governed by and interpreted in accordance with the laws of England and Wales. Any disputes will be subject to the exclusive jurisdiction of the courts of England and Wales.

11. Changes to Terms We may update these Terms at any time. Any changes will be communicated via our website. Your continued use of our services constitutes acceptance of the updated Terms.

Privacy Policy

1. Introduction At Brightpath Neuro, we value your privacy and are committed to protecting your personal information. This Privacy Policy outlines how we collect, use, store, and protect your data in compliance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

2. Data We Collect We collect the following types of personal data: Personal Information – Name, date of birth, contact details (email, phone, address). Health Information – Medical history, diagnostic information, and assessment data (only where necessary). Payment Information – Payment details processed securely through third-party providers. Usage Data – Information about how you use our website and services.

3. How We Collect Data We collect your data through: Direct interactions (e.g., booking forms, consultations). Automated technologies (e.g., cookies and website analytics). Third parties (e.g., referral agencies or medical professionals).

4. How We Use Your Data We use your personal data to: Provide and manage our services. Process payments and manage bookings. Communicate with you regarding your care and appointments. Improve our services and customer experience. Comply with legal and regulatory obligations.

5. Data Sharing We may share your data with: Medical professionals involved in your care (with your consent). Third-party payment processors (to process payments securely). Legal or regulatory bodies if required by law. We do not sell your data to third parties.

6. Data Retention We retain your data only for as long as necessary to fulfill the purposes outlined in this policy. Health records are retained in accordance with NHS guidelines and legal requirements.

7. Your Rights You have the right to: Access your data and request a copy of the information we hold. Request corrections to inaccurate or incomplete data. Request deletion of your data (where legally permitted). Object to the processing of your data for specific purposes. Withdraw consent for data processing at any time.

8. Data Security We implement appropriate security measures to protect your data, including encryption, secure servers, and restricted access.

9. Cookies Our website uses cookies to improve functionality and user experience. By continuing to use our site, you consent to the use of cookies as described in our Cookie Policy.

10. Complaints and Contact If you have any concerns about how we handle your data, you can contact us at: Email: [email protected] Phone: +44 20 3856 8602 You also have the right to lodge a complaint with the Information Commissioner's Office (ICO) if you believe your data rights have been violated.

11. Changes to This Policy We may update this Privacy Policy from time to time. Any changes will be posted on our website, and continued use of our services will constitute acceptance of the revised terms.

Medication Management Policy

1. Introduction

BrightPath Neuro is committed to ensuring the safe, effective, and appropriate management of medication for all service users. This policy outlines the framework for prescribing, dispensing, administering, and monitoring medications in line with legal, ethical, and professional standards. Medication management is integral to promoting the health and well-being of service users, minimising risks, and ensuring the delivery of high-quality care. By adhering to this policy, BrightPath Neuro ensures that all medications are managed safely and appropriately at all stages of care.

2. Purpose

The purpose of this policy is to :Define responsibilities and processes for managing medications safely and effectively. Ensure compliance with legal and regulatory requirements for medication management. Promote best practices in the prescribing, storage, administration, and disposal of medications. Safeguard service users by minimising risks associated with medication errors or misuse by adhering to this policy, BrightPath Neuro ensures that medication management practices meet the highest standards of safety, effectiveness, and accountability.

3. Scope

This policy applies to all employees, contractors, and volunteers involved in the prescribing, administration, or handling of medications. It covers all stages of medication management, including: Prescribing and transcribing. Storage and security. Administration and monitoring. Disposal of unused or expired medications. The policy is applicable across all BrightPath Neuro environments, including clinical settings, virtual platforms, and external collaborations.

4. Legislative Framework

This policy aligns with the following legislation and guidance: Medicines Act 1968:Governs the regulation, manufacture, and supply of medicines in the UK. The Misuse of Drugs Act 1971:Regulates the use of controlled substances to prevent misuse. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:Requires safe management of medicines as part of quality care. National Institute for Health and Care Excellence (NICE) Guidelines: Provides evidence-based recommendations for safe medication management. The Equality Act 2010:Ensures equitable access to medication and prevents discrimination in care. The Data Protection Act 2018 and GDPR: Protects the confidentiality of medication-related information. Compliance with these frameworks ensures that BrightPath Neuro meets legal and ethical responsibilities for managing medications safely and effectively.

5. Definitions.

Medication

Any substance prescribed or administered to prevent, treat, or manage health conditions, including prescription medicines, over-the-counter drugs, and controlled substances.

Prescriber

A qualified healthcare professional authorised to prescribe medications, such as doctors, nurse practitioners, or pharmacists.

Administration

The process of giving a medication to a service user, including oral, topical, injectable, and other routes.

Controlled Drugs

Medications regulated under the Misuse of Drugs Act 1971 due to their potential for misuse or harm.

6.Principles of Medication Management

BrightPath Neuro follows key principles to ensure the safe and effective management of medications: Person-Centered Care: Service users are involved in decisions about their medication and are provided with clear, accessible information. Safety: Measures are in place to minimise risks of medication errors or adverse effects. Compliance: Medication management practices comply with all relevant legislation, guidelines, and standards. Accountability: Staff are accountable for following protocols and reporting medication-related incidents or concerns. Confidentiality: Medication records and related information are kept secure and shared only with authorised individuals

7. Responsibilities

All staff involved in medication management are responsible for: Prescribing and Transcribing: Ensuring prescriptions are accurate, legible, and meet legal requirements. Storage and Security: Storing medications securely and in accordance with manufacturer guidelines. Administration: Administering medications correctly and documenting the process. Monitoring: Observing for therapeutic effects or adverse reactions and reporting concerns promptly. Disposal: Disposing of unused or expired medications safely and in line with regulations. The Medication Management Lead, Steven Davis, oversees medication management practices, ensuring compliance, providing training, and addressing any medication-related concerns.

8. Key Medication Management Practices

Prescribing: Only authorised prescribers may prescribe medications. Prescriptions must include the correct dosage, route, frequency, and duration. Storage: Medications are stored in a locked cabinet or secure area with access limited to authorised personnel. Controlled drugs are stored in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973.Administration: Medications are administered following the Five Rights: Right Person, Right Medication, Right Dose, Right Time, and Right Route. Staff must confirm the identity of the service user before administration. Monitoring and Review: Regular medication reviews are conducted to assess effectiveness and identify potential adverse effects. Service users are encouraged to provide feedback on their medication. Disposal: Expired or unused medications are disposed of using approved methods to prevent misuse or environmental harm.

9. Reporting Medication Incidents

If a medication error or incident occurs, staff must:Identify the Issue: Recognise and document the error or concern, including the date, time, and details of the incident.Inform the Medication Management Lead: Notify Steven Davis immediately for guidance and further action.Take Corrective Action: Implement measures to minimise harm to the service user, such as contacting emergency services if required.Document the Incident: Record the incident in the medication error log, including steps taken to address the issue.Review and Learn: Investigate the root cause of the incident and implement improvements to prevent recurrence.

10. Alignment with CQC Quality Statements and KLOEs

BrightPath Neuro’s medication management practices align with the CQC’s Quality Statements and Key Lines of Enquiry (KLOEs):Safe (S):Medications are managed safely, with protocols in place to minimise risks and errors. Effective (E):Medication practices are evidence-based and regularly reviewed for effectiveness. Caring (C):Service users’ preferences and concerns are respected, promoting dignity and trust. Responsive (R):Medication plans are tailored to meet the individual needs of service users. Well-Led (W):Leadership ensures robust medication management practices through training, audits, and oversight.

11. Monitoring and Review

This policy will be reviewed annually or following significant incidents, legislative updates, or organisational changes. Feedback from staff, service users, and stakeholders will inform updates to ensure the policy remains effective and up to date.

Wet Signature and Handwritten Prescription Policy

1. Purpose

This policy sets out the requirements for the prescribing of controlled drugs (CDs) at BrightPath Neuro, specifically addressing the requirement for wet signatures on prescriptions. While BrightPath Neuro supports the use of e-prescribing systems for standard medications, this policy ensures compliance with legal and regulatory frameworks regarding controlled drugs, which require a wet signature on prescriptions.

2. Scope

This policy applies to all prescribers, including but not limited to: Medical Practitioners Non-Medical Prescribers (NMPs) Pharmacists Clinical Leads It covers the prescribing of all medications listed under the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations 2001 that are classified as controlled substances.

3. Policy Statement

BrightPath Neuro recognises the importance of secure and accurate prescribing to safeguard patients and meet regulatory requirements. While electronic prescribing (e-prescribing) is permitted for general prescriptions, it cannot be used for controlled drugs due to legal requirements. For the prescribing of controlled drugs, the prescriber must provide a physical, handwritten prescription with a wet signature to ensure compliance with national and local guidelines.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidance: Misuse of Drugs Act 1971 Misuse of Drugs Regulations 2001 National Institute for Health and Care Excellence (NICE) Guidelines General Medical Council (GMC) Prescribing Standards Care Quality Commission (CQC) Requirements

5. Procedure

5.1 Prescriber Access and Authorisation for E-Prescribing

Prescribers are required to log into the BrightPath Neuro prescribing platform using their unique credentials. An individual authorisation code is sent to the prescriber’s registered device to confirm identity and authorise the prescription. E-prescribing is permitted for non-controlled medications only.

5.2 Controlled Drug Prescriptions

For controlled drugs, the following steps must be followed: Prescriber Responsibility: The prescriber must manually write the prescription on an approved prescription pad. The prescription must be fully completed with all required details, including: Full patient name and address Drug name, strength, and dosage Quantity prescribed (in words and figures) Directions for use Prescriber’s full name and registration number The prescription must be dated on the day it is written. Wet Signature Requirement: The prescriber must provide a wet signature (i.e., physically sign the prescription with ink). Digital signatures or electronic authorisation codes are not acceptable for controlled drugs. Prescription Handling: The completed prescription must be physically handed to the patient or securely sent to the dispensing pharmacy. Prescriptions must not be emailed, faxed, or electronically transmitted for controlled drugs. Record-Keeping: A copy of the prescription must be securely stored in the patient’s medical record. The prescriber must document the prescription details in the patient’s clinical notes, including the date, drug name, strength, quantity, and directions for use.

5.3 Emergency Prescribing of Controlled Drugs

In emergency situations where a controlled drug prescription is urgently required, the prescriber may issue a verbal order to the pharmacy only if permitted by law. The prescriber must follow up with a handwritten, wet-signed prescription within 24 hours.

5.4 Prescription Validity

Controlled drug prescriptions are valid for 28 days from the date of issue, unless otherwise specified by legislation. Repeat prescriptions for controlled drugs are not permitted unless under specific clinical circumstances approved by the clinical lead.

6. Monitoring and Compliance

The prescribing of controlled drugs will be monitored by the Clinical Lead and the Governance Team through regular audits. Any deviations from this policy or prescribing errors must be reported immediately to the Clinical Lead and documented in the incident reporting system. Non-compliance with this policy will be subject to investigation and may result in disciplinary action.

7. Training and Awareness

All prescribers must complete controlled drug prescribing training before being authorised to prescribe CDs. Regular updates on legislative changes and prescribing standards will be communicated to all clinical staff.

8. Responsibilities

8.1 Prescribers

Ensure compliance with this policy when prescribing controlled drugs. Maintain accurate and complete records of all prescriptions issued.

8.2 Clinical Lead

Oversee compliance with this policy and address any breaches or discrepancies. Provide guidance and support to prescribers on controlled drug prescribing.

8.3 Governance Team

Conduct audits and reviews of controlled drug prescribing. Ensure compliance with legal and regulatory frameworks.

9. Review

This policy will be reviewed annually or sooner if there are changes to legislation or clinical guidelines.

Handling and Security Policy Patient

1. Purpose

This policy sets out the procedures for the management, storage, and protection of patient data and prescription records at BrightPath Neuro. It ensures compliance with the UK General Data Protection Regulation (UK GDPR), the guidance of the Information Commissioner’s Office (ICO), and the standards outlined in ISO 9001. The objectives of this policy are to guarantee the secure and confidential handling of patient data and prescription records; to maintain accurate and up-to-date records of all prescriptions and clinical decisions; to safeguard patient data from unauthorised access, loss, or misuse; and to ensure full adherence to legal and regulatory requirements regarding data protection and clinical governance.

2. Scope

This policy applies to all personnel involved in prescribing, managing, or storing prescription records at BrightPath Neuro. This includes medical practitioners, non-medical prescribers (NMPs), clinical leads, pharmacists, and administrative staff. It covers all aspects of patient data and prescription records, including controlled drug prescriptions, electronic and handwritten prescriptions, patient health and medication histories, communications between prescribers and pharmacists, and incident reports related to prescribing errors or medication concerns.

3. Policy Statement

BrightPath Neuro is committed to the secure and confidential management of all patient data and prescription records. All procedures must comply with the UK GDPR, the Data Protection Act 2018, ICO guidelines, ISO 9001 Quality Management standards, CQC regulations, and the Misuse of Drugs Regulations 2001. All staff who handle patient data or prescription records are personally responsible for maintaining confidentiality at all times and ensuring that records are complete, accurate, and securely stored.

4. Legal and Regulatory Framework

This policy reflects compliance with the following legislation and standards: the UK General Data Protection Regulation (UK GDPR), the Data Protection Act 2018, ICO guidance, ISO 9001 Quality Management Systems, the Misuse of Drugs Regulations 2001, the Medicines Act 1968, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and NICE clinical guidelines.

5. Procedure

5.1 Prescription Record Keeping

All prescriptions must be recorded accurately. Non-controlled drug prescriptions must be entered electronically using the Signature RX platform. Controlled drug prescriptions must be issued in physical format, bearing a wet signature, and manually recorded in the Controlled Drug Register. Each prescription must be legible and accurate, dated and signed by an authorised prescriber, and must include the patient’s full name, address, and date of birth. The medication’s name, strength, dosage, and quantity (expressed in both figures and words for controlled drugs) must be documented. Prescription records must be retained for at least seven years following the patient’s last contact. In the event of a patient’s death, records must be kept for at least seven years from the date of death. The Controlled Drug Register must include the date of issue, drug details, quantity prescribed and dispensed, patient and prescriber information, and the dispensing pharmacist’s details. Any discrepancies in controlled drug records must be reported to the Clinical Lead and investigated immediately.

5.2 Data Protection and Confidentiality

All patient data is to be treated as strictly confidential. Staff may only access records when there is a clear clinical or operational need. Sharing of patient information with unauthorised individuals or external parties without patient consent is strictly prohibited unless legally required. Explicit patient consent must be obtained for sharing prescription records with external services such as pharmacies or specialist providers. This consent must be documented in the patient’s clinical record. Electronic prescription records must be stored securely using encrypted platforms such as Signature RX. Physical records, including controlled drug prescriptions, must be stored in locked cabinets with restricted access. Controlled drug registers should be stored separately from other prescription records. Only authorised clinical staff and prescribers may access prescription data. Systems must be protected using unique user credentials, multi-factor authentication (MFA), and audit logging. Any suspected or confirmed data breaches must be reported without delay to the Data Protection Officer (DPO) and Clinical Lead. If necessary, the ICO must be notified within 72 hours.

5.3 Prescription Amendments and Corrections

Errors on controlled drug prescriptions cannot be corrected. A new prescription must be issued if a mistake is discovered. Errors in electronic prescriptions may be amended electronically; the prescriber must update the clinical record and inform the pharmacy of the correction. All amendments must be clearly documented in the clinical record, with the date, time, and nature of the change recorded.

5.4 Disposal of Prescription Records

Electronic prescription records no longer required must be securely deleted in accordance with GDPR and ISO 9001 standards. Backups must also be securely deleted once the data retention period has ended. Physical prescription records must be securely destroyed, such as by shredding. Controlled drug registers are to be retained for a minimum of seven years before secure destruction.

5.5 Reporting and Audit

The Governance Team will carry out quarterly audits of prescription records to assess accuracy, completeness, and compliance with regulatory requirements. These audits will also help identify any prescribing trends or potential risks. Audit findings will be reported to the Clinical Lead and Governance Lead. Any areas of non-compliance will trigger corrective action and may result in additional staff training.

6. Monitoring and Compliance

Compliance with this policy will be monitored by the Governance Team through regular audits and the review of incidents. Any breaches of data protection or prescribing errors will be reported to the DPO and the Clinical Lead. Non-compliance with this policy may result in disciplinary action in accordance with BrightPath Neuro’s staff management procedures.

7. Training and Awareness

All staff involved in prescribing and record-keeping must complete training on GDPR principles, the safe handling of prescription records, secure use of electronic prescribing platforms, and the documentation of controlled drugs. Annual refresher training will be provided, and updates will be issued when relevant regulations or procedures change.

8. Responsibilities

8.1 Prescribers

Prescribers must ensure that all prescription records are accurate, complete, and securely managed. They must adhere to legal standards when prescribing and documenting controlled drugs.

8.2 Clinical Lead

The Clinical Lead is responsible for overseeing compliance with this policy, investigating any prescribing errors or data breaches, and ensuring proper documentation and escalation.

8.3 Governance Team

The Governance Team is tasked with conducting regular audits, identifying issues or trends, and implementing corrective actions as needed to maintain high standards.

9. Review

This policy shall be reviewed annually, or earlier if prompted by changes in legislation, regulatory guidance, or organisational practices.

Consent for Medication Policy

1. Introduction

Consent is a fundamental principle of ethical and legal healthcare practice. BrightPath Neuro is committed to ensuring that all individuals engaging with our services provide informed, voluntary, and valid consent before any assessment, treatment, or intervention. This policy provides a framework for obtaining, recording, and managing consent to respect the autonomy, rights, and dignity of all service users. By adhering to this policy, BrightPath Neuro ensures that individuals are fully informed and empowered to make decisions about their care.

2. Purpose

The purpose of this policy is to: Define the principles and processes for obtaining consent from service users. Ensure compliance with legal and ethical standards related to consent. Safeguard the rights and autonomy of individuals receiving care. Promote transparent communication and shared decision-making. By adhering to this policy, BrightPath Neuro upholds its commitment to person-centred care and ethical practice.

3. Scope

This policy applies to all employees, contractors, and volunteers involved in the provision of assessments, treatments, or other services at BrightPath Neuro. It encompasses all forms of consent, including: Verbal consent. Written consent. Implied consent (e.g., where actions indicate agreement).The policy applies across all BrightPath Neuro settings, including clinical environments, virtual platforms, and external engagements.

4. Legislative Framework

This policy aligns with the following legislation and guidance: The Mental Capacity Act 2005:Ensures individuals have the capacity to make decisions and provides guidance for obtaining consent when capacity is lacking. The Children Act 1989/2004:Outlines requirements for obtaining consent for children and young people under 18.The Human Rights Act 1998:Protects the right to autonomy, privacy, and freedom from inhumane or degrading treatment. The Data Protection Act 2018 and GDPR: Ensures that personal and sensitive data related to consent is handled lawfully and transparently. National Institute for Health and Care Excellence (NICE) Guidelines: Provides evidence-based recommendations for obtaining valid and informed consent. Compliance with these frameworks ensures that BrightPath Neuro meets its legal and ethical obligations regarding consent.

5. Definitions

Consent

Permission given by a service user to proceed with a proposed assessment, treatment, or intervention. Consent must be informed, voluntary, and given by an individual with capacity.

Informed Consent

Consent given with a full understanding of the proposed action, including its purpose, benefits, risks, and alternatives.

Capacity

The ability to understand, retain, and weigh information to make a specific decision and communicate that decision.

6. Principles of Consent

BrightPath Neuro follows key principles to ensure consent is obtained and managed appropriately: Informed Decision-Making: Service users are provided with clear, accurate, and accessible information to make informed choices. Voluntary Agreement: Consent is given freely, without coercion, undue influence, or pressure. Specificity: Consent is obtained for each specific assessment, treatment, or intervention. Capacity: Service users’ capacity to consent is assessed, particularly where there are doubts about their ability to make informed decisions. Ongoing Process: Consent is not a one-time event; it is an ongoing process, and individuals have the right to withdraw consent at any time.

7. Responsibilities

All staff involved in obtaining consent are responsible for: Providing Information: Explaining proposed assessments, treatments, and interventions, including risks and alternatives. Assessing Capacity: Ensuring the individual has the capacity to give consent and, if necessary, following the principles of the Mental Capacity Act 2005.Documenting Consent: Recording consent accurately, including details of discussions and decisions made. Respecting Decisions: Honoring the individual’s right to refuse or withdraw consent at any stage. The Consent Policy Lead, Steven Davis, provides oversight, guidance, and training to ensure compliance with this policy and associated legislation.

8. Types of Consent

Verbal Consent

Obtained through spoken agreement, particularly for non-invasive or low-risk procedures

Written Consent

Required for significant assessments, treatments, or interventions with potential risks. Written consent is recorded on an appropriate consent form.

Implied Consent

Inferred from the individual’s actions (e.g., offering an arm for a blood test). Implied consent must still be informed and voluntary.

9. Assessing Capacity

When there are concerns about an individual’s capacity to give consent, staff must: Assess the Decision: Identify the specific decision for which consent is required. Provide Support: Ensure the individual has all necessary information and tools to aid their decision-making. Assess Capacity: Determine if the individual can: Understand the information provided. Retain the information long enough to make a decision. Use or weigh the information in the decision-making process. Communicate their decision. Document Findings: Record the capacity assessment process, including outcomes and reasoning. If an individual is deemed to lack capacity, decisions must be made in their best interests following the Mental Capacity Act 2005.

10. Obtaining Consent from Children and Young People

Children Under 16:Consent must be obtained from a parent or legal guardian unless the child is deemed “Gillick competent” (able to understand the proposed intervention and its implications).Young People Aged 16-17:Presumed to have the capacity to consent unless there is evidence to the contrary. Best Interests: When consent cannot be obtained from a child or young person, decisions must be made in their best interests, involving parents or guardians where appropriate.

11. Documenting Consent

BrightPath Neuro ensures all consent is documented accurately, including: Details of discussions about risks, benefits, and alternatives. The individual’s decision, including any refusal or withdrawal of consent. Evidence of capacity assessments, if applicable. Signed consent forms for significant assessments or treatments.

12. Managing Refusal or Withdrawal of Consent

Service users have the right to refuse or withdraw consent at any stage. In such cases: Acknowledge the Decision: Respect the individual’s autonomy and their right to refuse or withdraw consent. Discuss Implications: Explain the potential consequences of refusing or withdrawing consent without applying pressure. Document the Refusal: Record the decision and the reasons provided (if given).Explore Alternatives: Offer alternative approaches or interventions where appropriate

13. Alignment with CQC Quality Statements and KLOEs

BrightPath Neuro’s consent practices align with the CQC’s Quality Statements and Key Lines of Enquiry (KLOEs):Safe (S):Consent is obtained before all assessments and treatments to protect service users from harm. Effective (E):Informed consent ensures service users understand and agree to their care plans. Caring (C):Consent practices respect the dignity, preferences, and autonomy of service users. Responsive (R):Consent processes adapt to individual needs, including capacity concerns and communication preferences. Well-Led (W):Leadership ensures compliance with consent standards through training, audits, and accountability.

14. Monitoring and Review

This policy will be reviewed annually or following significant incidents, legislative updates, or organisational changes. Feedback from service users, staff, and stakeholders will inform updates to ensure the policy remains effective and up to date.

Medication Storage and Disposal Policy

1. Purpose

The purpose of this policy is to clarify BrightPath Neuro’s position regarding the storage and disposal of medications. As a specialist assessment and prescribing service, BrightPath Neuro does not handle, store, or dispose of any medication on-site or within its premises. All medication-related logistics, including the dispensing, delivery, collection, and destruction of pharmaceuticals—including controlled drugs—are managed exclusively by our licensed pharmacy partner, Signature RX. This policy ensures compliance with the relevant legal frameworks while maintaining a clear division of responsibility and safeguarding both patients and staff from the risks associated with improper medication handling.

2. Scope

This policy applies to all clinicians, prescribers, administrative staff, and external partners working on behalf of BrightPath Neuro. It also serves to inform patients, caregivers, and external regulators of the organisation’s stance on medication storage and disposal.

3. Policy Statement

BrightPath Neuro operates as a prescribing and assessment service. We do not store, administer, deliver, or dispose of any medication under any circumstances. All such functions are performed by Signature RX, a registered and regulated pharmacy provider. This arrangement ensures full compliance with the Misuse of Drugs Regulations 2001, the Health and Social Care Act 2008, and Care Quality Commission (CQC) requirements regarding medication safety and handling. Where a prescription is issued by a BrightPath prescriber—either electronically for general medications or via wet signature for controlled substances—Signature RX assumes full responsibility for the safe dispensing, delivery, and where necessary, disposal of that medication.

4. Storage of Medication

No medication, including controlled drugs, over-the-counter products, or medical samples, is held at any BrightPath Neuro location or by any member of staff. All prescriptions are transmitted directly to Signature RX, and no stock is kept under our control. BrightPath staff are prohibited from personally storing or transporting medication on behalf of patients or the organisation. Patients are instructed to store their medication at home in accordance with pharmacy guidance, ensuring medications are kept in original packaging, away from heat, moisture, and out of reach of children. Patients are reminded that improper storage may affect medication effectiveness or safety.

5. Disposal of Medication

BrightPath Neuro does not accept or facilitate the return, disposal, or destruction of unused, expired, or unwanted medications. Patients are directed to return any such items to their dispensing pharmacy—usually Signature RX or their nominated local pharmacy—for appropriate disposal in accordance with national guidelines. Where a prescribing change or discontinuation occurs, the prescriber will ensure that the patient is given verbal and written advice on safe disposal routes. Under no circumstances should BrightPath staff accept medication from a patient for disposal, nor should any medication be discarded via household waste or standard office refuse.

6. Collaborative Responsibility

Signature RX BrightPath Neuro works in close partnership with Signature RX, a fully licensed pharmacy provider, to ensure that all handling of medication—including transportation, packaging, delivery, and disposal—is performed in compliance with national standards and pharmacy regulations. Signature RX maintains full responsibility for: The lawful and secure storage of medication within its facilities Appropriate cold-chain or controlled drug storage (as required) Safe destruction of returned or expired medications Compliance with the Controlled Drugs (Supervision of Management and Use) Regulations Any incidents or concerns raised by Signature RX relating to medication handling or storage are communicated to the Clinical Lead at BrightPath Neuro and addressed in accordance with our governance and incident reporting framework.

7. Staff Responsibilities

All staff must adhere to this policy and avoid any actions that imply the storage or physical handling of medication. Prescribers are responsible for ensuring that patients understand their responsibilities around safe storage and disposal. Administrative and clinical staff must direct any disposal or return enquiries to Signature RX or the patient’s nominated community pharmacy.

8. Training and Awareness

All BrightPath staff receive induction and annual training on our medication-related policies, including this policy and our prescribing protocols. Staff are reminded regularly of the organisation’s position on storage and disposal, and what to do in the event of an incident, breach, or patient enquiry.

9. Review

This policy shall be reviewed annually or sooner if there are changes in legislation, prescribing arrangements, or the pharmacy partnership.

Medication Availability and Stock Check

1. Purpose

This policy outlines the procedures for ensuring medication availability at BrightPath Neuro. While BrightPath Neuro does not hold or stock medications on-site, it is essential to ensure that prescribed medications are readily available to patients through partner pharmacies. This policy ensures that medication availability is monitored and managed effectively in collaboration with Signature RX and other pharmacy partners.

2. Scope

This policy applies to all staff involved in the prescribing and management of medications at BrightPath Neuro, including but not limited to: Medical Practitioners Non-Medical Prescribers (NMPs) Clinical Leads Pharmacists Nursing and Healthcare Staff It covers the prescribing and monitoring of all medications, including: Controlled Drugs (CDs) Prescription-Only Medicines (POM) Over-the-Counter (OTC) Medications Specialist Medications

3. Policy Statement

BrightPath Neuro is committed to ensuring that all prescribed medications are accessible to patients without delay or disruption. Although BrightPath Neuro does not hold or stock medications on-site, effective systems are in place to: Monitor medication availability through Signature RX and partner pharmacies. Ensure prescriptions are issued accurately and promptly. Work closely with pharmacies to resolve any medication supply issues.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971 Misuse of Drugs Regulations 2001 Medicines Act 1968 National Institute for Health and Care Excellence (NICE) Guidelines Care Quality Commission (CQC) Requirements

5. Procedure

5.1 Medication Availability

Monitoring Pharmacy Partnership (Signature RX): BrightPath Neuro maintains an agreement with Signature RX and other designated pharmacies to supply prescribed medications. Availability of medications will be checked regularly via Signature RX to ensure sufficient supply. Any identified issues with medication supply or stock levels will be communicated to the Clinical Lead and prescribers. Prescriber Responsibility: Prescribers are responsible for ensuring that prescribed medications are available at the designated pharmacy. Prescribers must check medication availability through Signature RX before issuing prescriptions for specialist or high-demand medications. Controlled Drugs: Controlled drug prescriptions must comply with national and local regulations. Prescribers should confirm the availability of controlled drugs with Signature RX before issuing a prescription. If a controlled drug is unavailable, alternative options should be discussed with the patient and the pharmacist.

5.2 Prescribing Process

Electronic Prescriptions: All prescriptions for non-controlled medications should be issued electronically through the Signature RX platform. Prescribers must log into their Signature RX account using secure credentials and an individual authorisation code. The prescription is sent directly to the designated pharmacy via Signature RX for processing. Controlled Drugs: Controlled drug prescriptions require a physical, handwritten prescription with a wet signature from the prescriber. Controlled drug prescriptions cannot be issued electronically through Signature RX. Prescribers must confirm with Signature RX that the medication is available before issuing the prescription. If the medication is unavailable, prescribers should explore suitable alternatives with the pharmacist. Repeat Prescriptions: Repeat prescriptions for non-controlled medications can be issued electronically through Signature RX. Repeat prescriptions for controlled drugs are generally not permitted unless authorised by the Clinical Lead. Prescribers must confirm medication availability before issuing repeat prescriptions.

5.3 Pharmacy Liaison and Communication

Routine Monitoring: The Clinical Lead or designated staff member will liaise with Signature RX and partner pharmacies weekly to monitor medication availability and supply issues. Any supply issues or shortages will be reported to the prescriber and Clinical Lead immediately. Patient Notification: If a prescribed medication is unavailable, the patient will be informed promptly. The prescriber will work with the pharmacy and patient to identify an appropriate alternative medication where possible. Medication Delays: If medication delivery is delayed, Signature RX will notify BrightPath Neuro. The prescriber will be informed and will provide guidance to the patient regarding next steps or alternative options.

5.4 Handling Medication

Supply Issues Short-Term Supply Issues: If a medication is temporarily out of stock, the prescriber will consider issuing an alternative medication. The Clinical Lead will liaise with Signature RX to monitor when the medication is expected to become available. Long-Term Supply Issues: If a medication is unavailable long-term, the prescriber will work with the pharmacy and the patient to establish a suitable alternative. If no alternative is available, the Clinical Lead will consult with a specialist pharmacist for further guidance. Controlled Drugs: If a controlled drug is unavailable, the prescriber should contact the Clinical Lead and Signature RX for alternative options. If no alternative is available, the patient should be referred to a specialist service for review.

5.5 Emergency Situations

Urgent Medication Needs: In emergency situations, the prescriber will contact the designated pharmacy directly to confirm availability and arrange immediate supply where possible. If the medication is unavailable, the prescriber will consult with the Clinical Lead for next steps. Emergency Controlled Drugs: Emergency prescriptions for controlled drugs must comply with national regulations. Verbal orders for controlled drugs are not permitted. Emergency controlled drug prescriptions must be issued with a wet signature and delivered directly to the pharmacy within 24 hours.

6. Monitoring and Compliance

Prescribing Records: All prescriptions issued through Signature RX will be logged and monitored. Any discrepancies or prescribing errors must be reported to the Clinical Lead immediately. Audit and Review: The Clinical Lead will conduct a monthly audit of prescribing records and medication availability reports. Findings will be reviewed with Signature RX to address any supply issues or process improvements. Incident Reporting: Any medication supply issues or prescribing errors must be reported through the incident reporting system. The Clinical Lead will investigate all incidents and recommend corrective actions.

7. Training and Awareness

All prescribers must complete training on the use of Signature RX and controlled drug regulations. Regular training on prescribing procedures and medication availability will be provided to all clinical staff. Updates on supply issues and prescribing trends will be shared with staff through clinical meetings and communications.

8. Responsibilities

8.1 Prescribers

Ensure prescriptions are accurate and comply with legal requirements. Confirm medication availability through Signature RX before issuing prescriptions. Work with the pharmacy to resolve any medication supply issues.

8.2 Clinical Staff

Monitor medication availability through Signature RX and report any supply issues. Support patients in accessing medications and addressing any concerns.

8.3 Clinical Lead

Oversee medication availability processes and prescribing practices. Liaise with Signature RX and other partner pharmacies to monitor supply and resolve issues.

8.4 Governance Lead

Conduct regular audits of prescribing practices and medication availability. Investigate and resolve medication availability issues.

9. Incident Reporting and Investigation

Any medication shortages or errors must be reported immediately. The Clinical Lead will investigate the incident and implement corrective actions. Serious issues will be escalated to the Director of Nursing and Education.

10. Review

This policy will be reviewed annually or sooner if there are changes to legislation or pharmacy supply agreements

Procedure Delivery and Collection of Controlled Drugs Policy

1. Purpose

This policy establishes the procedures and guidelines for the delivery and collection of controlled drugs (CDs) prescribed by BrightPath Neuro. As BrightPath Neuro does not deliver or collect controlled drugs, this policy clarifies the roles and responsibilities of prescribers, patients, and partner organisations such as Signature RX in ensuring the secure and compliant handling of controlled drugs.

2. Scope

This policy applies to all staff involved in the prescribing and management of controlled drugs at BrightPath Neuro, including but not limited to: Medical Practitioners Non-Medical Prescribers (NMPs) Clinical Leads Pharmacists Administrative Staff It covers the prescribing and handling of controlled drugs under the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations 2001, including: Schedule 1 – High-risk drugs (e.g., cannabis) Schedule 2 – High-risk drugs (e.g., morphine, oxycodone) Schedule 3 – Moderate-risk drugs (e.g., tramadol, buprenorphine) Schedule 4 – Lower-risk drugs (e.g., diazepam) Schedule 5 – Lowest-risk drugs (e.g., codeine, certain cough syrups)

3. Policy Statement

BrightPath Neuro does not handle, store, deliver, or collect controlled drugs directly. Instead, all controlled drugs prescribed by BrightPath Neuro are managed and supplied through external partner pharmacies, including Signature RX. Prescriptions for controlled drugs must comply with national and local regulations, and the delivery and collection of controlled drugs remain the responsibility of the patient, the pharmacy, and the designated delivery service (if applicable).

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971 Misuse of Drugs Regulations 2001 Medicines Act 1968 National Institute for Health and Care Excellence (NICE) Guidelines Care Quality Commission (CQC) Requirements

5. Procedure

5.1 Prescribing of Controlled Drugs

Authorised Prescribers: Only authorised medical practitioners and non-medical prescribers (NMPs) are permitted to issue prescriptions for controlled drugs. Prescriptions must include: Patient’s full name, address, and date of birth Drug name, strength, and dosage Total quantity prescribed (in figures and words) Directions for use Prescriber’s full name, registration number, and wet signature Controlled Drug Prescription Format: Controlled drug prescriptions cannot be issued electronically through Signature RX. A physical, handwritten prescription with a wet signature is required. The prescription must be dated on the day of issue and is valid for 28 days from the date of signing. Prescription Transmission: Once signed, the prescription can either: Be handed directly to the patient, OR Sent securely to Signature RX or another designated pharmacy by registered post or secure courier. Controlled drug prescriptions must never be emailed or faxed.

5.2 Delivery and Collection of Controlled Drugs

Responsibility for Delivery and Collection: BrightPath Neuro does not deliver or collect controlled drugs. Signature RX or another designated pharmacy is responsible for coordinating the delivery or collection of controlled drugs. Patients or their authorised representatives are responsible for collecting controlled drugs from the pharmacy unless delivery has been arranged directly with the pharmacy. Pharmacy Arrangements: Signature RX will manage delivery and collection arrangements directly with the patient. The pharmacy is responsible for ensuring that: Controlled drugs are stored and handled in line with legal and professional guidelines. The person collecting the controlled drug presents appropriate identification. The delivery is documented in accordance with controlled drug regulations. Identification and Authorisation: Patients must provide valid identification (e.g., passport or driver’s licence) when collecting controlled drugs from the pharmacy. If an authorised representative is collecting the medication, they must provide: A letter of authorisation signed by the patient. Identification of both the representative and the patient (where applicable). Home Delivery (Optional): Signature RX or the designated pharmacy may offer a home delivery service for controlled drugs. Delivery must comply with the Misuse of Drugs Regulations 2001. The pharmacy will confirm the delivery with the patient and obtain a signature upon receipt.

5.3 Emergency Prescribing and Collection of Controlled Drugs

Emergency Prescribing: Emergency controlled drug prescriptions can be issued when clinically necessary. Verbal orders for controlled drugs are not permitted under any circumstances. Emergency prescriptions must be handwritten, signed, and delivered to the pharmacy within 24 hours. Emergency Collection: If an emergency prescription is required, the patient or their representative is responsible for collecting the medication from the pharmacy. Signature RX may arrange same-day delivery where possible. The pharmacy must document the emergency collection or delivery in the Controlled Drug Register.

5.4 Documentation and Record-Keeping

Prescribing Records: All controlled drug prescriptions must be documented in the patient’s medical record, including: Medication name, strength, and dosage Date of issue Prescriber’s details Delivery or collection method Records must be retained for a minimum of 7 years in compliance with data protection regulations. Pharmacy Records: Signature RX or the designated pharmacy is responsible for maintaining a Controlled Drug Register in line with legal requirements. All controlled drug deliveries and collections must be logged, including: Patient’s name Date of collection or delivery Quantity supplied Name and signature of the person collecting the medication

5.5 Handling Issues and Discrepancies

Failed Delivery: If a controlled drug delivery fails, the pharmacy will contact the patient directly to reschedule delivery or arrange collection. The failed delivery must be recorded in the Controlled Drug Register. Lost or Stolen Controlled Drugs: If a controlled drug is lost or stolen during delivery or collection, the pharmacy is responsible for: Conducting an investigation Reporting the incident to the Controlled Drugs Accountable Officer Reporting the incident to the police (if necessary) Prescription Errors: If a prescription error is identified before collection or delivery: The prescriber must be contacted immediately. A new prescription must be issued if required.

6. Monitoring and Compliance

All controlled drug prescriptions will be logged and monitored by the Clinical Lead. Regular audits of controlled drug prescribing and handling processes will be conducted by the Governance Lead. Any discrepancies or failures in the delivery or collection process will be reviewed and corrective action taken. The Clinical Lead will maintain oversight of compliance with the Misuse of Drugs Regulations 2001.

7. Training and Awareness

All prescribers and clinical staff must complete training on controlled drug prescribing and compliance. Refresher training will be provided annually or when changes to legislation or guidelines occur. Signature RX and partner pharmacies will provide updates on delivery and collection procedures.

8. Responsibilities

8.1 Prescribers

Ensure controlled drug prescriptions are accurate and legally compliant. Confirm medication availability with Signature RX before issuing prescriptions.

8.2 Clinical Staff

Support patients in understanding delivery and collection processes. Report any issues with prescriptions or delivery to the Clinical Lead.

8.3 Clinical Lead

Monitor prescribing and collection processes. Liaise with Signature RX and other partner pharmacies to address issues.

9. Review

This policy will be reviewed annually or sooner if there are changes to legislation or pharmacy supply agreements.

Emergency Prescription Policy

1. Purpose

This policy sets out the procedure for issuing emergency prescriptions at BrightPath Neuro. It ensures that patients receive timely access to necessary medications in emergency situations while maintaining compliance with national guidelines and legal requirements, especially in relation to controlled drugs.

2. Scope

This policy applies to all staff involved in the prescribing and management of medications at BrightPath Neuro, including but not limited to: Medical Practitioners Non-Medical Prescribers (NMPs) Clinical Leads Pharmacists It covers the emergency prescribing of: Controlled Drugs (CDs) – Schedule 1 to Schedule 5 under the Misuse of Drugs Regulations 2001 Prescription-Only Medicines (POM) Over-the-Counter (OTC) Medications Specialist Medications

3. Policy Statement

BrightPath Neuro is committed to ensuring that patients have prompt access to medications in emergency situations. The prescribing of emergency medications must follow established legal and clinical guidelines to prevent misuse, ensure patient safety, and maintain proper documentation. Prescribing procedures differ depending on whether the medication is a controlled drug or a non-controlled drug.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971 Misuse of Drugs Regulations 2001 Medicines Act 1968 National Institute for Health and Care Excellence (NICE) Guidelines Care Quality Commission (CQC) Requirements

5. Procedure

5.1 Emergency Prescribing for Non-Controlled Drugs

Authorised Prescribers: Only authorised medical practitioners and non-medical prescribers (NMPs) are permitted to issue emergency prescriptions. Prescriptions must include: Patient's full name, address, and date of birth Drug name, strength, and dosage Total quantity prescribed Directions for use Prescriber’s full name, registration number, and signature Prescribing Method: Non-controlled emergency medications can be prescribed electronically through the Signature RX platform. The prescriber must log into the Signature RX system using secure credentials and a unique authorisation code. The prescription will be transmitted directly to the designated pharmacy for immediate processing. Follow-Up: The prescriber must document the emergency prescription in the patient's medical record within 24 hours. Any issues with the emergency prescription must be reported to the Clinical Lead immediately.

5.2 Emergency Prescribing for Controlled Drugs

Authorised Prescribers: Only authorised medical practitioners and non-medical prescribers (NMPs) are permitted to issue emergency controlled drug prescriptions. Prescriptions for controlled drugs must comply with the Misuse of Drugs Regulations 2001 and require additional documentation and verification. Prescribing Method: Controlled drug prescriptions cannot be issued electronically through Signature RX. The prescriber must issue a handwritten prescription with a wet signature. The prescription must include: Patient's full name, address, and date of birth Drug name, strength, and dosage Total quantity prescribed (in figures and words) Directions for use Prescriber’s full name, registration number, and signature Transmission and Handling: The signed prescription must be physically handed to the patient or sent directly to the pharmacy by secure means (e.g., registered post or secure courier). Prescriptions for controlled drugs must never be transmitted electronically or by fax. Follow-Up: If the prescription is issued verbally (in exceptional cases), the prescriber must: Confirm the verbal order with the pharmacy. Issue a signed, handwritten prescription within 24 hours. The prescriber must document the emergency prescription in the patient's medical record within 24 hours. Controlled Drug Register: The pharmacy is responsible for recording the controlled drug prescription in the Controlled Drug Register. Any discrepancies or failures in supply must be reported to the Clinical Lead and logged in the incident reporting system.

5.3 Prescribing Limits and Restrictions

Controlled Drug Quantities: Emergency prescriptions for controlled drugs should be limited to the shortest possible supply to meet the immediate clinical need (usually up to 5 days’ supply). Larger quantities may only be prescribed with clinical justification and approval from the Clinical Lead. High-Risk Medications: Prescriptions for Schedule 1 drugs (e.g., cannabis) are only permitted for research purposes or with specific legal authorisation. Schedule 2 and Schedule 3 drugs require additional oversight and documentation. Repeat Prescriptions: Emergency prescriptions for controlled drugs cannot be issued as repeat prescriptions. Emergency prescriptions for non-controlled medications may be repeated only with clinical justification.

5.4 Pharmacy Liaison and Communication

Communication with Signature RX: The prescriber must confirm with Signature RX that the prescribed medication is available before issuing an emergency prescription. If the medication is unavailable, the prescriber should consult with the pharmacy to identify suitable alternatives. Delivery and Collection: Signature RX is responsible for coordinating the delivery or collection of the emergency prescription. The patient or their authorised representative is responsible for collecting the medication unless delivery has been arranged. Controlled drugs must only be collected or delivered following ID verification and proper documentation.

5.5 Documentation and Record-Keeping

Medical Records: All emergency prescriptions must be documented in the patient’s medical record within 24 hours of issue. Records must include: Drug name, strength, and dosage Date and time of issue Method of delivery or collection Prescriber’s name and signature Pharmacy Records: Signature RX or the designated pharmacy is responsible for maintaining records of emergency prescriptions. Controlled drugs must be logged in the Controlled Drug Register in line with legal requirements.

5.6 Incident Reporting and Investigation

Medication Errors: Any errors in the prescribing, handling, or delivery of emergency medications must be reported immediately to the Clinical Lead. All medication errors must be logged and investigated within 48 hours. Failed Delivery or Collection: If an emergency medication delivery or collection fails, the prescriber must be notified immediately. The prescriber will reassess the situation and issue a new prescription if necessary.

6. Monitoring and Compliance

All emergency prescriptions will be monitored by the Clinical Lead and reviewed monthly. Any discrepancies or patterns of prescribing irregularities will be investigated and addressed. Emergency controlled drug prescriptions will be reviewed against the Controlled Drug Register to ensure compliance with the Misuse of Drugs Regulations.

7. Training and Awareness

All prescribers must complete training on emergency prescribing and controlled drug regulations. Refresher training will be provided annually or when changes to legislation or prescribing guidelines occur. Clinical staff will receive updates on pharmacy procedures and medication availability.

8. Responsibilities

8.1 Prescribers

Ensure emergency prescriptions comply with legal and clinical guidelines. Confirm medication availability before issuing emergency prescriptions.

8.2 Clinical Lead

Monitor emergency prescribing practices and compliance. Investigate medication errors and implement corrective actions.

8.3 Pharmacy (Signature RX)

Ensure prompt delivery or collection of emergency medications. Maintain accurate records of controlled drug prescriptions.

9. Review

This policy will be reviewed annually or sooner if there are changes to legislation or pharmacy supply agreements.

Pharmacy and Dispensing Agreement Policy

1. Purpose

This policy outlines the agreement between BrightPath Neuro and its designated pharmacy partner, Signature RX, for the management and dispensing of medications. BrightPath Neuro does not directly handle, store, dispense, or deliver medications; instead, all prescriptions are processed and managed through Signature RX or other designated pharmacy partners. This policy ensures that prescribing and dispensing arrangements meet all legal and regulatory requirements and that patients receive medications in a timely and safe manner.

2. Scope

This policy applies to all staff involved in the prescribing and management of medications at BrightPath Neuro, including but not limited to: Medical Practitioners Non-Medical Prescribers (NMPs) Clinical Leads Administrative Staff It covers all medication types prescribed at BrightPath Neuro, including: Controlled Drugs (CDs) – Schedule 1 to Schedule 5 under the Misuse of Drugs Regulations 2001 Prescription-Only Medicines (POM) Over-the-Counter (OTC) Medications Specialist Medications

3. Policy Statement

BrightPath Neuro operates under a formal dispensing agreement with Signature RX, which is responsible for managing all aspects of medication supply, dispensing, and delivery. BrightPath Neuro’s role is limited to issuing prescriptions and ensuring compliance with clinical and regulatory standards. The agreement with Signature RX ensures that: All prescribed medications are dispensed accurately and promptly. Controlled drugs are handled in accordance with national regulations. Prescribing and dispensing records are maintained accurately. Medication delivery and collection are managed securely and efficiently.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971 Misuse of Drugs Regulations 2001 Medicines Act 1968 National Institute for Health and Care Excellence (NICE) Guidelines Care Quality Commission (CQC) Requirements

5. Procedure

5.1 Prescribing and Transmission of Prescriptions

Authorised Prescribers: Only authorised medical practitioners and non-medical prescribers (NMPs) are permitted to issue prescriptions. Prescriptions must include: Patient’s full name, address, and date of birth Drug name, strength, dosage, and total quantity prescribed Directions for use Prescriber’s full name, registration number, and signature Electronic Prescriptions (Non-Controlled Drugs): Prescriptions for non-controlled medications are issued electronically through the Signature RX platform. The prescriber must log into Signature RX using secure credentials and a unique authorisation code. The prescription will be transmitted directly to Signature RX for processing. Controlled Drug Prescriptions: Controlled drug prescriptions cannot be issued electronically. A physical, handwritten prescription with a wet signature is required. The signed prescription can be: Handed directly to the patient, OR Sent securely to Signature RX by registered post or secure courier. Signature RX will dispense the controlled drug upon receipt of the original signed prescription. Repeat Prescriptions: Repeat prescriptions for non-controlled medications can be issued electronically through Signature RX. Controlled drugs are generally not eligible for repeat prescriptions unless specifically authorised by the Clinical Lead.

5.2 Pharmacy Responsibilities (Signature RX)

Under the terms of the agreement, Signature RX is responsible for: Dispensing and Supply: Ensuring that all prescribed medications are dispensed accurately and promptly. Confirming the availability of medications before processing prescriptions. Informing BrightPath Neuro if any medication is unavailable or in short supply. Controlled Drug Handling: Maintaining a Controlled Drug Register in line with legal requirements. Ensuring that controlled drugs are stored in a locked, secure cabinet with restricted access. Recording all controlled drug prescriptions in the Controlled Drug Register. Verifying the identity of the person collecting a controlled drug. Delivery and Collection: Signature RX is responsible for arranging delivery or collection of medications. Medications can only be collected by the patient or an authorised representative with valid identification. For home delivery, the pharmacy must obtain a signature upon receipt of the medication. Emergency Prescriptions: Signature RX must have a process for handling emergency prescriptions, including controlled drugs. Emergency controlled drug prescriptions must be confirmed with the prescriber before dispensing. Emergency prescriptions must be documented and handled in compliance with legal requirements.

5.3 Patient Responsibilities

Collection: Patients are responsible for collecting medications from Signature RX unless delivery has been arranged. Patients must provide valid identification when collecting controlled drugs. If a representative is collecting on behalf of the patient, they must provide: A signed authorisation letter from the patient Identification of both the patient and the representative Missed Collections: If the patient fails to collect the medication within the pharmacy’s collection window, Signature RX will notify the prescriber. The prescriber may decide to issue a new prescription if appropriate.

5.4 Handling Issues and Discrepancies

Dispensing Errors: If a dispensing error occurs, Signature RX must notify the prescriber immediately. The pharmacy must: Withdraw the incorrect medication. Issue a replacement prescription if clinically appropriate. Record the incident in the incident reporting system. Controlled Drug Discrepancies: If a discrepancy in controlled drug stock or documentation is identified: Signature RX must report the issue to the Controlled Drugs Accountable Officer. The discrepancy must be investigated and documented in the Controlled Drug Register. The prescriber must be notified of the outcome of the investigation. Supply Shortages: If a prescribed medication is unavailable, Signature RX must notify the prescriber immediately. The prescriber will decide whether to: Issue an alternative prescription, OR Advise the patient to wait until the medication becomes available.

5.5 Documentation and Record-Keeping

Prescriber Documentation: All prescriptions must be documented in the patient’s clinical record within 24 hours of issue. Records must include: Drug name, strength, and dosage Date and time of prescription Method of collection or delivery Prescriber’s details Pharmacy Documentation: Signature RX is responsible for maintaining accurate dispensing records. Controlled drugs must be recorded in the Controlled Drug Register in compliance with legal requirements. Any discrepancies or incidents must be logged and reported to BrightPath Neuro.

6. Monitoring and Compliance

Prescribing and dispensing activity will be monitored through regular audits. Any discrepancies or failures in dispensing must be reported to the Clinical Lead. Compliance with the agreement will be reviewed with Signature RX annually. Signature RX will provide monthly reports on dispensing activity and controlled drug handling.

7. Training and Awareness

All prescribers must complete training on prescribing processes and controlled drug handling. Signature RX will provide annual updates on dispensing and delivery processes. Staff involved in medication prescribing will receive training on pharmacy agreements and patient responsibilities.

8. Responsibilities

8.1 Prescribers

Ensure prescriptions are accurate and legally compliant. Confirm medication availability with Signature RX before issuing prescriptions.

8.2 Clinical Lead

Monitor compliance with prescribing and dispensing agreements. Investigate prescribing or dispensing discrepancies.

8.3 Signature RX

Ensure timely and accurate dispensing of medications. Manage controlled drug stock and compliance.

9. Review

This policy will be reviewed annually or sooner if there are changes to legislation or pharmacy agreements.

Physical Health Monitoring Policy Side Effect

1. Purpose

This policy sets out the procedures for physical health monitoring and the management of medication-related side effects at BrightPath Neuro. It ensures that all patients prescribed medications known to carry physical health risks undergo appropriate baseline and ongoing health checks. The purpose is to identify, prevent, and manage any potential adverse effects associated with such medications. The policy is specifically concerned with medications that may impact cardiovascular, metabolic, neurological, and endocrine systems. Where clinically indicated, additional checks such as electrocardiograms (ECGs), blood pressure readings, blood tests, and anthropometric measurements (such as height and weight) will be undertaken.

2. Scope

This policy applies to all staff involved in prescribing and monitoring medications at BrightPath Neuro. This includes medical practitioners, non-medical prescribers (NMPs), clinical leads, and nursing or healthcare staff. The scope includes physical health monitoring in relation to a variety of medications, including but not limited to: psychotropic medications (e.g., antipsychotics, antidepressants, mood stabilisers), cardiovascular medications (e.g., beta-blockers), stimulants (e.g., methylphenidate, amphetamines), metabolic medications (e.g., treatments for diabetes or weight management), and specialist medications such as anti-epileptics.

3. Policy Statement

BrightPath Neuro is committed to the safe prescribing and careful monitoring of all medications with known physical health implications. This commitment is upheld by conducting comprehensive baseline assessments prior to the initiation of high-risk medications, ensuring regular monitoring to detect and address any side effects, referring patients to specialists when needed, educating patients about possible risks, and responding promptly to emerging concerns.

4. Legal and Regulatory Framework

This policy is aligned with current national standards and guidance, including those issued by the National Institute for Health and Care Excellence (NICE), the Medicines Act 1968, the Misuse of Drugs Act 1971, and the Misuse of Drugs Regulations 2001. It also adheres to the regulatory requirements set by the Care Quality Commission (CQC), the General Medical Council (GMC) prescribing guidelines, and information from the British National Formulary (BNF).

5. Procedure

5.1 Baseline Physical Health Checks

Before initiating any high-risk medication, baseline checks must be carried out where clinically appropriate. These include ECGs for cardiovascular concerns, blood pressure and heart rate monitoring, blood tests to assess liver and renal function, lipid and glucose profiles, and measurements of height and weight. Prolactin levels may also be required when using antipsychotic medications. These checks are typically carried out by the prescriber in collaboration with nurses, phlebotomists, or healthcare assistants, depending on the nature of the assessment.

5.2 Ongoing Monitoring and Frequency

Physical health checks will be repeated at regular intervals, unless otherwise clinically indicated. For example, blood pressure and heart rate should be monitored every three months when stimulants are prescribed, and annually for those on antipsychotics. ECGs are to be conducted annually or as needed, and weight or BMI should be checked every six months for those taking antipsychotics or mood stabilisers. Annual blood tests, including liver and renal function, glucose, and lipid levels, are essential for patients on long-term treatment. Monitoring prolactin levels annually is also recommended for individuals taking antipsychotic medication.

5.3 Managing Side Effects

Side effects should be categorised by severity. Mild symptoms such as dizziness or dry mouth should be noted, with patients offered reassurance and symptom management advice. Moderate side effects, including increased heart rate or noticeable weight gain, should prompt a medication review. The prescriber may choose to adjust the dosage, consider alternative medications, or implement more frequent monitoring. Severe or serious side effects—such as QTc prolongation, significant metabolic changes, or organ impairment—necessitate immediate medical attention. In these cases, the medication may be discontinued, the patient referred for urgent specialist review, and emergency support initiated if needed.

5.4 Patient Education and Consent

Patients must be fully informed about the possible physical health risks associated with their medications. Informed, written consent should be obtained for any high-risk medication, and patients should be encouraged to report any new or worsening symptoms without delay.

5.5 Referral and Escalation

If significant changes in physical health are identified, the prescriber must refer the patient to an appropriate specialist, such as a cardiologist or endocrinologist. Medication may need to be adjusted or stopped, and all decisions and referrals should be clearly documented in the patient’s clinical record.

6. Monitoring and Compliance

All physical health monitoring data must be accurately recorded in the patient’s clinical records. The Clinical Lead will conduct quarterly reviews to monitor compliance with the required schedules and identify any deviations or emerging concerns. Any significant side effects or lapses in monitoring will be documented and thoroughly investigated.

7. Training and Awareness

All prescribers are required to complete mandatory training on the physical health monitoring requirements for psychotropic and other high-risk medications. Clinical staff must receive regular training in areas such as ECG interpretation, blood pressure and heart rate measurement, and the management of side effects. Annual refresher training or ad hoc updates will be provided whenever relevant clinical guidelines change.

8. Responsibilities

8.1 Prescribers

Prescribers are responsible for ensuring that all baseline and ongoing monitoring is carried out, and for managing any side effects appropriately and in accordance with clinical guidance.

8.2 Clinical Staff

Clinical staff are responsible for conducting physical health checks, accurately documenting all findings, and promptly escalating any significant concerns to the prescriber.

8.3 Clinical Lead

The Clinical Lead is responsible for ensuring compliance with this policy, supporting staff with clinical decision-making, and guiding the management of any complex side effects or medication adjustments.

9. Review

This policy shall be reviewed annually, or earlier if changes to legislation, clinical guidelines, or prescribing practices necessitate an update.

Monitoring and Reporting Policy

1. Purpose

This policy outlines the framework for monitoring and reporting procedures at BrightPath Neuro, aimed at ensuring robust oversight of both clinical and operational functions. It provides clear guidance for the identification, documentation, and response to issues, incidents, and emerging trends through a structured reporting system. The central objective is to guarantee accurate monitoring of all clinical and operational data, prompt reporting of incidents or concerns, and the effective implementation of corrective actions. This approach ensures the maintenance of high standards of care and full compliance with applicable regulatory requirements.

2. Scope

This policy applies to all staff involved in monitoring, recording, and reporting clinical and operational activities within BrightPath Neuro. This includes, but is not limited to, medical practitioners, non-medical prescribers (NMPs), clinical leads, the governance team, administrative personnel, and members of the online reporting team. Areas covered under this policy include clinical activity, medication prescribing and administration, patient safety incidents, complaints and feedback, adverse events and near misses, safeguarding issues, and matters relating to regulatory and compliance obligations.

3. Policy Statement

BrightPath Neuro is committed to upholding a structured and effective monitoring and reporting process designed to ensure patient safety and the delivery of high-quality care. This process also enables the organisation to maintain compliance with statutory and regulatory frameworks, identify and address risks or trends in a timely manner, and foster a culture of continuous learning and improvement. Accurate and transparent reporting to both internal and external stakeholders is a key principle of this policy. The Online Reporting Team is responsible for logging all incidents via the online reporting platform, while the Clinical and Governance Teams are tasked with reviewing, investigating, and acting on these reports accordingly.

4. Legal and Regulatory Framework

This policy is aligned with the requirements set out by the Care Quality Commission (CQC), the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and guidance from the National Institute for Health and Care Excellence (NICE). It also adheres to professional standards established by the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC).

5. Procedure

5.1 Reporting Structure

The Online Reporting Team is responsible for the timely and accurate logging of incidents and issues within the designated online system. Each report must include the date and time of the incident, a description, individuals involved, any immediate action taken, and the current status or resolution. Reports should be submitted within 24 hours of the event. Upon submission, the Clinical and Governance Teams will review the report. The Governance Team will categorise it according to severity and risk, while the Clinical Team will investigate clinical incidents and propose appropriate actions. The Governance Team oversees operational and regulatory concerns, ensuring that corrective actions are executed.

5.2 Types of Reports

Incidents must be reported under the following categories: Clinical Incidents (e.g., medication errors, misdiagnoses): Logged by the Online Reporting Team and investigated by the Clinical Team. Medication and Prescription Issues (e.g., delays, errors, side effects): Initially logged and referred to the Clinical Team. Patient Safety Incidents (e.g., falls, breaches of confidentiality, safeguarding): Escalated to the Clinical and Safeguarding Leads. Operational Issues (e.g., staffing shortages, IT failures): Managed by the Governance Team. Complaints and Feedback (e.g., dissatisfaction, communication issues): Handled by the Governance Team. Near Misses and Safeguarding Concerns: Escalated to the relevant Clinical and Governance leads.

5.3 Incident Classification and Risk Assessment

Incidents will be classified by the Governance Team according to severity and risk: Low Risk: Minimal impact – logged and monitored, no immediate action. Moderate Risk: Noticeable impact – investigation and corrective action within 72 hours. High Risk: Significant impact – immediate investigation and resolution within 24 hours. Critical Risk: Life-threatening – urgent response required, with immediate notification to the Clinical and Governance Leads.

5.4 Investigation and Resolution

All reports must be reviewed within 24 hours. Immediate action will be taken if required to ensure safety. Investigations will involve a review of relevant documentation, identification of root causes, and an evaluation of procedural compliance. Corrective actions may include policy updates, training, disciplinary action, or equipment maintenance. The resolution process must be documented and reviewed for effectiveness. Once complete, the investigation will be closed, and all relevant parties, including patients, will be informed of the outcome.

5.5 Learning and Feedback

All incidents are reviewed quarterly by the Governance Team to identify patterns and opportunities for organisational learning. Lessons learned will be shared through team meetings and internal communications, and any necessary improvements or training updates will be implemented as part of ongoing service development.

5.6 Reporting to External Agencies

Serious incidents may require notification to external regulatory bodies, such as the CQC, the MHRA, the GMC, the NMC, or local safeguarding authorities. The Governance Lead will assess each situation and manage the external reporting process as appropriate.

6. Monitoring and Compliance

The Governance Lead will undertake quarterly audits of incident logs and the outcomes of investigations. Compliance with reporting deadlines and investigation standards will be monitored, and any failure to report or address incidents appropriately will be subject to performance management and potential disciplinary action.

7. Training and Awareness

All staff are required to complete mandatory training covering incident reporting procedures, root cause analysis, and safeguarding requirements. Annual refresher training will be provided or updated in response to changes in relevant policies or systems.

8. Responsibilities

8.1 Online Reporting

Team Responsible for the accurate and timely logging of all incidents within 24 hours.

8.2 Clinical and Governance

Teams Responsible for reviewing reports, conducting investigations, and implementing corrective actions.

8.3 Governance Lead

Oversees the overall incident management process and ensures compliance with external reporting obligations.

8.4 Clinical Lead

Manages responses to clinical incidents and ensures the resolution of patient safety concerns.

9. Review

This policy shall be reviewed on an annual basis or earlier if there are significant changes to legislation or reporting procedures.

Annual Review and Reassessment Policy

1. Purpose

This policy establishes the framework for conducting annual reviews and reassessments at BrightPath Neuro. The purpose is to ensure that all individuals receiving care and treatment are reviewed annually to evaluate the effectiveness of their treatment plans, medication regimens, and overall clinical outcomes. Annual reviews and reassessments are vital for maintaining person-centred, evidence-based care that reflects each patient’s evolving needs and the latest clinical guidance. This policy guarantees that such reviews are carried out in a structured and consistent manner and that findings from the reassessment process are used to update care plans and enhance service delivery.

2. Scope

This policy applies to all clinical and administrative staff involved in reviewing and reassessing patients at BrightPath Neuro. This includes medical practitioners, non-medical prescribers (NMPs), clinical leads, members of the governance team, and nursing or healthcare staff. It applies to patients prescribed psychotropic medications (e.g., antipsychotics, antidepressants, mood stabilisers), those on controlled drugs (e.g., stimulants, opioid-based medications), individuals receiving behavioural or psychosocial interventions, those under complex care management plans, and patients with co-existing physical or mental health conditions.

3. Policy Statement

BrightPath Neuro is committed to ensuring that all patients receive comprehensive, regular reviews to evaluate treatment effectiveness, monitor for side effects or risks, detect any changes in clinical presentation or personal circumstances, and make timely adjustments to care plans. The objective is to maintain care that is safe, effective, person-centred, and in line with best practice. Annual reviews are a core component of clinical governance and are essential for maintaining high standards of care and compliance with regulatory obligations.

4. Legal and Regulatory Framework

This policy aligns with the requirements of the Care Quality Commission (CQC) Regulations, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the National Institute for Health and Care Excellence (NICE) Guidelines. It also reflects the prescribing standards set by the General Medical Council (GMC), the Nursing and Midwifery Council (NMC) Code of Practice, and recommendations from the British National Formulary (BNF).

5. Procedure

5.1 Frequency of Annual Reviews

All patients under the care of BrightPath Neuro must receive a formal review at least once every twelve months. However, more frequent reviews may be necessary where there is a significant change in the individual’s mental or physical health, when medication side effects or adverse reactions are noted, following the introduction of a new treatment plan, if concerns arise around medication compliance or effectiveness, or where there are safety or safeguarding concerns.

5.2 Types of Annual Review

The nature of each review will vary depending on the patient's diagnosis, clinical needs, and treatment plan. The following types of reviews must be conducted as appropriate:

5.2.1 Medication Review

A medication review should include an assessment of current prescriptions, including dosage, compliance, and any side effects. It must also evaluate the effectiveness of the medication, assess interactions or contraindications, and consider any necessary changes based on clinical evidence and patient feedback. All adjustments must be discussed with the patient and documented in their clinical record.

5.2.2 Physical Health Review

Patients taking high-risk medications or with underlying health concerns should undergo a physical health review, which may include monitoring blood pressure and heart rate, conducting ECGs (if cardiac risks are present), measuring height and weight, and conducting blood tests (e.g., glucose, cholesterol, liver and renal function, and prolactin levels where indicated).

5.2.3 Mental Health Review

This review must assess the patient’s mood, anxiety, behaviour, sleep, appetite, and cognitive function. It should include a review of any suicidal ideation or risk behaviours, assess daily functioning, and gather feedback from the patient (or caregiver) about their experience of treatment. The findings will inform updates to the care plan.

5.2.4 Psychosocial and Behavioural Review

Where therapy forms part of the treatment plan, this review should assess the patient's engagement with interventions, progress towards therapeutic goals, and any emerging social or environmental challenges that may affect progress.

5.2.5 Risk Review

A risk review must be completed for patients identified as presenting a risk to themselves or others. This includes safeguarding concerns, medication-related risks such as overdose potential, and legal or social care-related risks. All risk factors must be recorded, and any changes in risk level must trigger appropriate clinical or safeguarding action.

5.3 Review Process

Patients should be notified of their annual review appointment at least two weeks in advance. The clinical team will gather and review relevant records in preparation. Reviews must be conducted by qualified clinicians or prescribers using a standardised template to ensure completeness and consistency. Any proposed changes to treatment must be discussed with the patient, and their informed consent must be obtained. All findings must be documented clearly in the clinical record, including changes to medication, emerging risks, and planned follow-up. Urgent concerns must be escalated immediately to the Clinical Lead.

5.4 Patient Involvement and Consent

Patients should be actively engaged in their care planning and annual review process. Informed consent must be obtained before any changes to treatment are made. Patients must be given accessible information about the purpose of the review, any potential side effects or risks, and alternative treatment options where relevant.

5.5 Escalation and Referral

If the annual review identifies significant health concerns, the clinician must update the care plan or medication accordingly, make referrals to relevant specialists (e.g., cardiology, neurology), inform the Clinical Lead of high-risk findings, and, where appropriate, initiate safeguarding referrals.

6. Monitoring and Compliance

The Clinical Lead is responsible for overseeing the completion of annual reviews. The Governance Team will carry out quarterly audits of clinical records to confirm that reviews are completed on schedule, actions are fully documented, and any missed or overdue reviews are investigated and addressed.

7. Training and Awareness

All prescribers and clinical staff must complete training on the annual review process. This includes how to conduct structured reviews, assess physical and mental health indicators, apply safe prescribing practices, and ensure effective patient communication and consent. Refresher training will be delivered annually or when relevant guidance changes.

8. Responsibilities

8.1 Prescribers

Prescribers must ensure that annual reviews are completed within the required timeframe and must respond appropriately to any clinical findings or concerns identified during the process.

8.2 Clinical Staff

Clinical staff are responsible for assisting with physical health checks, accurately documenting findings, and escalating any concerns to the relevant prescriber or Clinical Lead.

8.3 Clinical Lead

The Clinical Lead oversees the annual review process, ensures policy compliance, and investigates any gaps or missed reviews.

9. Review

This policy will be reviewed annually or earlier if changes in legislation, clinical guidelines, or best practice necessitate an update.

Data Protection and Prescription Record Keeping Policy

1. Purpose

This policy sets out the procedures for the management, storage, and protection of patient data and prescription records at BrightPath Neuro. It ensures compliance with the UK General Data Protection Regulation (UK GDPR), the guidance of the Information Commissioner’s Office (ICO), and the standards outlined in ISO 9001. The objectives of this policy are to guarantee the secure and confidential handling of patient data and prescription records; to maintain accurate and up-to-date records of all prescriptions and clinical decisions; to safeguard patient data from unauthorised access, loss, or misuse; and to ensure full adherence to legal and regulatory requirements regarding data protection and clinical governance.

2. Scope

This policy applies to all personnel involved in prescribing, managing, or storing prescription records at BrightPath Neuro. This includes medical practitioners, non-medical prescribers (NMPs), clinical leads, pharmacists, and administrative staff. It covers all aspects of patient data and prescription records, including controlled drug prescriptions, electronic and handwritten prescriptions, patient health and medication histories, communications between prescribers and pharmacists, and incident reports related to prescribing errors or medication concerns.

3. Policy Statement

BrightPath Neuro is committed to the secure and confidential management of all patient data and prescription records. All procedures must comply with the UK GDPR, the Data Protection Act 2018, ICO guidelines, ISO 9001 Quality Management standards, CQC regulations, and the Misuse of Drugs Regulations 2001. All staff who handle patient data or prescription records are personally responsible for maintaining confidentiality at all times and ensuring that records are complete, accurate, and securely stored.

4. Legal and Regulatory Framework

This policy reflects compliance with the following legislation and standards: the UK General Data Protection Regulation (UK GDPR), the Data Protection Act 2018, ICO guidance, ISO 9001 Quality Management Systems, the Misuse of Drugs Regulations 2001, the Medicines Act 1968, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and NICE clinical guidelines.

5. Procedure

5.1 Prescription Record Keeping

All prescriptions must be recorded accurately. Non-controlled drug prescriptions must be entered electronically using the Signature RX platform. Controlled drug prescriptions must be issued in physical format, bearing a wet signature, and manually recorded in the Controlled Drug Register. Each prescription must be legible and accurate, dated and signed by an authorised prescriber, and must include the patient’s full name, address, and date of birth. The medication’s name, strength, dosage, and quantity (expressed in both figures and words for controlled drugs) must be documented. Prescription records must be retained for at least seven years following the patient’s last contact. In the event of a patient’s death, records must be kept for at least seven years from the date of death. The Controlled Drug Register must include the date of issue, drug details, quantity prescribed and dispensed, patient and prescriber information, and the dispensing pharmacist’s details. Any discrepancies in controlled drug records must be reported to the Clinical Lead and investigated immediately.

5.2 Data Protection and Confidentiality

All patient data is to be treated as strictly confidential. Staff may only access records when there is a clear clinical or operational need. Sharing of patient information with unauthorised individuals or external parties without patient consent is strictly prohibited unless legally required. Explicit patient consent must be obtained for sharing prescription records with external services such as pharmacies or specialist providers. This consent must be documented in the patient’s clinical record. Electronic prescription records must be stored securely using encrypted platforms such as Signature RX. Physical records, including controlled drug prescriptions, must be stored in locked cabinets with restricted access. Controlled drug registers should be stored separately from other prescription records. Only authorised clinical staff and prescribers may access prescription data. Systems must be protected using unique user credentials, multi-factor authentication (MFA), and audit logging. Any suspected or confirmed data breaches must be reported without delay to the Data Protection Officer (DPO) and Clinical Lead. If necessary, the ICO must be notified within 72 hours.

5.3 Prescription Amendments and Corrections

Errors on controlled drug prescriptions cannot be corrected. A new prescription must be issued if a mistake is discovered. Errors in electronic prescriptions may be amended electronically; the prescriber must update the clinical record and inform the pharmacy of the correction. All amendments must be clearly documented in the clinical record, with the date, time, and nature of the change recorded.

5.4 Disposal of Prescription Records

Electronic prescription records no longer required must be securely deleted in accordance with GDPR and ISO 9001 standards. Backups must also be securely deleted once the data retention period has ended. Physical prescription records must be securely destroyed, such as by shredding. Controlled drug registers are to be retained for a minimum of seven years before secure destruction.

5.5 Reporting and Audit

The Governance Team will carry out quarterly audits of prescription records to assess accuracy, completeness, and compliance with regulatory requirements. These audits will also help identify any prescribing trends or potential risks. Audit findings will be reported to the Clinical Lead and Governance Lead. Any areas of non-compliance will trigger corrective action and may result in additional staff training.

6. Monitoring and Compliance

Compliance with this policy will be monitored by the Governance Team through regular audits and the review of incidents. Any breaches of data protection or prescribing errors will be reported to the DPO and the Clinical Lead. Non-compliance with this policy may result in disciplinary action in accordance with BrightPath Neuro’s staff management procedures.

7. Training and Awareness

All staff involved in prescribing and record-keeping must complete training on GDPR principles, the safe handling of prescription records, secure use of electronic prescribing platforms, and the documentation of controlled drugs. Annual refresher training will be provided, and updates will be issued when relevant regulations or procedures change.

8. Responsibilities

8.1 Prescribers

Prescribers must ensure that all prescription records are accurate, complete, and securely managed. They must adhere to legal standards when prescribing and documenting controlled drugs.

8.2 Clinical Lead

The Clinical Lead is responsible for overseeing compliance with this policy, investigating any prescribing errors or data breaches, and ensuring proper documentation and escalation.

8.3 Governance Team

The Governance Team is tasked with conducting regular audits, identifying issues or trends, and implementing corrective actions as needed to maintain high standards.

9. Review

This policy shall be reviewed annually, or earlier if prompted by changes in legislation, regulatory guidance, or organisational practices.

Complaints and Incidents Reporting Policy

1. Purpose

This policy sets out the framework for managing complaints and incident reporting at BrightPath Neuro to ensure that all feedback, concerns, and incidents are handled promptly, fairly, and consistently. The purpose of this policy is to: Provide a clear and accessible process for patients, carers, staff, and stakeholders to raise complaints and report incidents. Ensure that all complaints and incidents are investigated promptly and thoroughly. Identify and address the root causes of complaints and incidents. Support a culture of openness, learning, and continuous improvement. Ensure compliance with regulatory and legal requirements.

2. Scope

This policy applies to all staff and stakeholders at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Governance Team, Administrative Staff, External Partners (e.g., Signature RX)It covers the reporting and management of: Patient and carer complaints Staff complaints and grievances Clinical incidents (e.g., medication errors, patient injury)Non-clinical incidents (e.g., IT failures, security issues)Safeguarding issues Data breaches and confidentiality breaches, near misses and risks

3. Policy Statement

BrightPath Neuro is committed to: Maintaining a culture of openness and transparency. Providing a clear and straightforward process for reporting complaints and incidents. Investigating all complaints and incidents thoroughly and without bias. Taking corrective action to prevent recurrence. Maintaining the confidentiality and dignity of all individuals involved. Learning from complaints and incidents to improve service quality and patient care.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Care Quality Commission (CQC) Regulations Health and Social Care Act 2008 (Regulated Activities) Regulations 2014NHS Complaints Regulations 2009General Medical Council (GMC) Professional Standards Nursing and Midwifery Council (NMC) Code of Conduct Data Protection Act 2018UK General Data Protection Regulation (UK GDPR)Freedom of Information Act 2000

5. Procedure

5.1 Complaints Handling Process

5.1.1 Raising a Complaint

Complaints can be raised by: Patients, carers, or family members, Staff members, External stakeholders (e.g., partner organisations)Complaints may be submitted: Verbally – In person or by phone In Writing – By letter or email online – Through the BrightPath Neuro website or patient portal Anonymously – Where the complainant wishes to remain unidentified

5.1.2 Initial Acknowledgement

All complaints must be acknowledged within 2 working days of receipt. The acknowledgment should include: Confirmation that the complaint has been received. An estimated timeframe for resolution. Contact details of the person handling the complaint.

5.1.3 Investigation

The Governance Team will: Assign a responsible person (e.g., Clinical Lead or Governance Lead) to investigate the complaint. Interview relevant staff and review any related documentation (e.g., patient notes, prescribing records).Assess the validity of the complaint and identify contributing factors. Ensure that the investigation is completed within 10 working days (or longer if the complaint is complex).Keep the complainant informed of progress.

5.1.4 Resolution and Response

A formal response will be provided to the complainant within 10 working days of the investigation’s conclusion. The response will include: A summary of the investigation findings. An explanation of any corrective action taken. An apology if appropriate. Details of the next steps or ongoing support. Information about how to escalate the complaint (if required).

5.1.5 Learning and Follow-Up

Findings from complaints will be shared with relevant teams through clinical governance meetings. Lessons learned will be integrated into staff training and policy updates where appropriate. Complaints trends will be reviewed quarterly to identify patterns and systemic issues.

5.2 Incident Reporting Process

5.2.1 Definition of an Incident

An incident is defined as: Any event that causes or has the potential to cause harm to a patient, staff member, or visitor. Any breach of data security or confidentiality. Any medication error or prescribing issue. Any safeguarding concern. Any health and safety issue

5.2.2 Incident Reporting

All incidents must be reported via the BrightPath Neuro Online Reporting System within 24 hours of the event occurring. Incidents must include: Date and time of the incident, Location, Description of the incident, Individuals involved, Immediate actions taken.

5.2.3 Classification of Incidents

The Governance Team will classify incidents based on severity: Category Description, Action Required, Low No or minimal harm, no ongoing impact, Review at monthly governance meeting, Moderate: Short-term harm or operational disruption, Investigation and corrective action within 5 working days, High Serious harm or operational failure, Immediate investigation and resolution within 24 hours, Critical Life-threatening or catastrophic impact, Emergency response and external reporting within 24 hours

5.2.4 Investigation and Resolution

The Governance Lead will assign an investigator. The investigation will include: Interviewing staff involved. Reviewing patient records and related documentation. Identifying any policy breaches or procedural failures. Determining the root cause of the incident. A full investigation report must be completed within 10 working days of the incident

5.2.5 Corrective Action

Corrective actions may include: Updating policies and procedures. Providing staff training. Adjusting medication or treatment protocols. Disciplinary action where appropriate. All corrective actions must be monitored for effectiveness.

5.2.6 Reporting to External Authorities

Serious incidents may require external reporting to: Care Quality Commission (CQC)Medicines and Healthcare Products Regulatory Agency (MHRA)General Medical Council (GMC)Nursing and Midwifery Council (NMC)Safeguarding authorities. The Governance Lead will determine the need for external reporting and coordinate the process.

5.3 Escalation of Complaints and Incidents

If the complainant is not satisfied with the resolution, they may escalate the complaint to: The Clinical Lead or Governance Lead. The Care Quality Commission (CQC).The Parliamentary and Health Service Ombudsman.

6. Monitoring and Compliance

All complaints and incidents will be logged and monitored by the Governance Team. Quarterly trend analysis will be conducted to identify patterns and areas for improvement. The Clinical and Governance Leads will review all high-risk incidents and complaints. Any failure to comply with this policy may result in disciplinary action.

7. Training and Awareness

All staff must complete training on complaints handling and incident reporting. Staff involved in investigations must complete root cause analysis training. Refresher training will be provided annually or when guidelines are updated.

8. Responsibilities

8.1 Governance Lead

Oversee the investigation of complaints and incidents. Ensure compliance with external reporting requirements.

8.2 Clinical Lead

Respond to clinical complaints and incidents. Ensure corrective actions are implemented.

8.3 Staff

Report all incidents and complaints promptly.Cooperate fully with investigations.

9. Review

This policy will be reviewed annually or sooner if there are changes to legislation or clinical guidelines.

Audit and Compliance Monitoring Policy

1. Purpose

This policy establishes the framework for conducting audits and monitoring compliance at BrightPath Neuro to ensure that clinical, operational, and governance standards are consistently met. The purpose of this policy is to: Ensure that all clinical and operational activities comply with internal policies and external regulatory requirements. Identify areas for improvement and implement corrective actions. Promote a culture of accountability, transparency, and continuous improvement. Ensure that findings from audits and monitoring activities are used to improve patient care and service delivery.

2. Scope

This policy applies to all staff at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Governance Team, Administrative Staff, External Partners (e.g., Signature RX)It covers the audit and compliance monitoring of: Clinical care and patient safety, Medication management and prescribing practices, Patient and staff records, Data protection and confidentiality, Staff training and competency, Governance and risk management processes, Financial and operational activities

3. Policy Statement

BrightPath Neuro is committed to: Conducting regular audits and compliance monitoring to ensure adherence to clinical, operational, and regulatory standards. Using a structured and consistent approach to monitor performance. Identifying and addressing non-compliance and areas for improvement. Promoting a learning culture where staff are encouraged to participate in audits and compliance reviews. Ensuring that all audit findings are reviewed and acted upon to enhance patient care and service delivery.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Care Quality Commission (CQC) Regulations Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Professional Standards Nursing and Midwifery Council (NMC) Code of Conduct Medicines Act 1968Misuse of Drugs Regulations 2001National Institute for Health and Care Excellence (NICE) Guidelines ISO 9001 – Quality Management Systems UK General Data Protection Regulation (UK GDPR)

5. Procedure

5.1 Types of Audits

BrightPath Neuro will carry out the following types of audits to monitor compliance and improve service quality:

Type of Audit. Description. Frequency. Responsibility. Clinical Audit. Reviews clinical care against NICE guidelines and clinical best practices. Quarterly. Clinical Lead. Prescribing and Medication Audit. Reviews prescribing patterns, medication errors, and adherence to drug regulations. Quarterly. Pharmacist and Clinical Lead. Data Protection Audit. Reviews handling of patient data and compliance with GDPR and ICO guidelines. Annually. Governance Lead. Health and Safety Audit. Reviews compliance with health and safety policies, including infection control. Quarterly. Health and Safety Officer. Staff Training and Competency Audit. Reviews staff compliance with training requirements and professional development. Annually. Training Manager. Financial and Operational Audit. Reviews budget allocation, financial procedures, and operational performance. Annually. Governance Lead and Finance Manager. Patient Feedback and Complaints Audit. Reviews patient complaints, feedback, and resolution processes. Quarterly. Governance Lead

5.2 Clinical Audit Process

Selection of Audit Topics: Clinical audit topics will be selected based on: National clinical guidelines (e.g., NICE)Areas of high clinical risk or medication errors, Patient feedback and complaints. Findings from previous audits, the Clinical Lead will approve the audit plan annually.

Data Collection:

Data will be collected through: Patient records, Prescription records, Staff interviews and feedback, Incident reports. All data collection methods will comply with data protection regulations.

Analysis:

Data will be analysed to identify: Compliance with clinical guidelines, Trends and patterns, Variations from best practice, Root causes of errors or failures

Reporting:

A clinical audit report will be prepared and shared with: Clinical Governance Committee, Clinical Lead and Prescribers, Executive Management Team (if applicable)The report will include: Summary of findings, Areas of good practice, Areas for improvement, Recommended corrective actions

Implementation and Monitoring:

An action plan will be developed to address areas of non-compliance. The Clinical Lead will monitor the implementation of corrective actions. A follow-up audit will be conducted within 3 months to ensure that corrective actions have been completed.

5.3 Medication and Prescribing Audit Process

Scope:

All prescribing and medication management practices will be audited. Special attention will be given to controlled drugs, psychotropic medications, and high-risk prescriptions.

Data Sources:

Signature RX records, Patient clinical notes, Incident and medication error reports

Analysis:

Review prescribing patterns for appropriateness and compliance with national guidelines. Identify medication errors and patterns of adverse effects. Assess compliance with controlled drug regulations.

Reporting and Action:

A medication audit report will be prepared. Recommendations for improving prescribing practices will be implemented. Outcomes will be monitored through follow-up audits.

5.4 Data Protection Audit Process

Scope:

Review access to patient records. Ensure compliance with GDPR and ICO standards. Assess handling of confidential information.

Key Elements:

Staff access permissions, Data storage and encryption, Patient consent for information sharing, Data breaches and incident response

Outcome:

Identify gaps in compliance. Implement corrective actions. Provide staff training on data protection where necessary.

5.5 Financial and Operational Audit

Scope:

Review of budget allocation and financial practices. Review of operational efficiency and resource use. Identify discrepancies and financial risks.

Outcome:

Recommendations for improving financial and operational efficiency. Implementation of corrective actions.

5.6 Compliance Monitoring

Audit Schedule:

The Governance Lead will develop and maintain an annual audit schedule. All audits must be completed according to the agreed schedule.

Compliance Reporting:

A quarterly compliance report will be submitted to the Executive Management Team. The report will include: Status of audits, Summary of findings, Corrective actions and outcomes

Incident Reporting:

All non-compliance issues identified during audits must be reported to the Governance Lead. Serious non-compliance issues must be reported to the Executive Management Team immediately.

6.Monitoring and Compliance

The Governance Lead will oversee the completion of all audits. Audit findings will be reviewed by the Clinical Governance Committee. Performance will be measured against key performance indicators (KPIs).Non-compliance will be addressed through corrective action plans.

7. Training and Awareness

All staff involved in audits must complete training on audit processes. Staff will be informed of audit findings and corrective actions. Annual refresher training will be provided.

8. Responsibilities

8.1 Governance Lead

Oversee the annual audit schedule. Ensure all audits are completed on time.

8.2 Clinical Lead

Monitor clinical audit outcomes. Implement corrective actions.

8.3 Staff

Participate in audits as required. Cooperate fully with the audit process.

9. Review

This policy will be reviewed annually or sooner if there are changes to legislation or clinical guidelines.

Missed and Late Prescriptions Policy

1. Purpose

This policy sets out the procedures for managing missed and late prescriptions at BrightPath Neuro to ensure that patients receive timely and uninterrupted access to prescribed medications. It establishes clear guidelines for responding to missed or delayed prescriptions to minimise the impact on patient care and safety. The purpose of this policy is to: Ensure that all prescriptions are processed and delivered within agreed timeframes. Provide a structured approach to managing missed and late prescriptions. Reduce the risk of medication errors, withdrawal symptoms, and deterioration of health due to missed prescriptions. Clarify the responsibilities of prescribers, pharmacy partners (e.g., Signature RX), and clinical staff in managing missed and late prescriptions.

2. Scope

This policy applies to all staff involved in the prescribing, management, and delivery of medications at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Pharmacists (e.g., Signature RX)Administrative Staff, Clinical Governance Team, It covers: Electronic prescriptions, Controlled drug prescriptions, Repeat prescriptions, Emergency prescriptions

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all prescriptions are processed and delivered promptly. Providing patients with clear information about prescription timelines and collection arrangements. Minimising the risk of missed or delayed prescriptions. Responding promptly and effectively to missed or delayed prescriptions. Working closely with Signature RX and other partner pharmacies to resolve prescription issues promptly.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Medicines Act 1968Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Practice, Care Quality Commission (CQC) Regulations, National Institute for Health and Care Excellence (NICE) Guidelines

5. Procedure

5.1 Prescription Processing and Delivery Timeframes

Standard Prescriptions: Non-controlled drug prescriptions should be processed within 24 hours of being issued. Prescriptions must be transmitted electronically through Signature RX (or the designated pharmacy) using secure prescribing platforms. Controlled Drug Prescriptions: Controlled drug prescriptions cannot be issued electronically and require a wet signature. Controlled drug prescriptions must be processed and ready for collection within 48 hours of being issued. The original signed prescription must be delivered to the pharmacy (via secure courier or post) within 24 hours of issue. Repeat Prescriptions: Repeat prescriptions should be requested by the patient at least 5 working days before the next supply is required. Repeat prescriptions should be processed and ready for collection within 48 hours of the request. Emergency Prescriptions: Emergency prescriptions must be processed immediately. If a controlled drug prescription is issued in an emergency, a signed prescription must be sent to the pharmacy within 24 hours. Emergency prescriptions should only cover a short-term supply (up to 5 days) until a full prescription can be issued.

5.2 Identifying a Missed or Late Prescription

A prescription is classified as missed or late if: The patient does not receive the medication within the expected timeframe. The pharmacy (e.g., Signature RX) reports a delay or failure to process the prescription. The patient reports a missed or delayed prescription.

5.3 Managing a Missed or Late Prescription

If a missed or late prescription is identified, the following steps must be taken:

5.3.1 Non-Controlled Drug Prescription

Investigation: Confirm that the prescription was issued and transmitted to the pharmacy. Contact Signature RX (or the designated pharmacy) to confirm the status of the prescription.

Action: If the prescription was not received by the pharmacy, reissue the prescription immediately. If the prescription was delayed due to an administrative or system error, correct the issue and notify the patient. If the pharmacy reports a stock issue, identify an alternative pharmacy or medication.

Patient Notification: Inform the patient of the reason for the delay. Provide an estimated time for when the medication will be available. Offer guidance on managing symptoms while awaiting the medication. Follow-Up: Ensure that the patient receives the medication within 24 hours of resolving the issue. Record the incident in the patient's clinical record. Report the delay to the Governance Lead for

review.

5.3.2 Controlled Drug Prescription

Investigation: Confirm that the prescription was issued, signed, and transmitted to the pharmacy. Contact Signature RX (or the designated pharmacy) to confirm receipt of the original signed prescription.

Action: If the pharmacy did not receive the prescription, issue a new signed prescription immediately. If the prescription was lost during transmission, notify the Clinical Lead and issue a new prescription. If the delay is due to a stock issue, work with the pharmacy to identify an alternative supplier.

Patient Notification: Inform the patient of the reason for the delay. Advise the patient on managing withdrawal symptoms (if applicable).Consider issuing an emergency prescription if clinically appropriate.

Follow-Up: Ensure that the patient receives the medication within 24 hours of resolving the issue. Record the incident in the Controlled Drug Register and the patient’s clinical record. Report the incident to the Clinical Lead and Governance Lead.

5.4 Reporting and Incident Logging

All missed and late prescriptions must be logged in the Online Incident Reporting System. Reports must include: Patient details (name, DOB, contact information)Date and time of the missed or delayed prescription, Type of medication, Reason for the delay, Actions taken to resolve the issue, Outcome and follow-up actions, Serious incidents involving controlled drugs or significant harm to the patient must be escalated to: Clinical Lead, Governance Lead, Care Quality Commission (CQC) (if required)

5.5 Corrective Actions and Learning

The Clinical Lead and Governance Lead will review all missed and late prescription incidents. Corrective actions may include: Updating prescribing and delivery procedures, Staff training, Improving communication with partner pharmacies, Addressing systemic issues or IT failures, Lessons learned from incidents will be shared with staff through clinical governance meetings.

6. Monitoring and Compliance

The Governance Team will monitor the frequency and causes of missed and late prescriptions through regular audits. Key Performance Indicators (KPIs) for missed and late prescriptions will be reviewed quarterly. Any trends or recurring issues will be addressed through corrective actions and policy updates.

7. Training and Awareness

All prescribers and clinical staff must complete training on: Prescription processing and transmission protocols, Handling controlled drug prescriptions, Managing stock shortages and alternative prescribing options, Communicating delays and issues with patients, Annual refresher training will be provided.

8. Responsibilities

8.1 Prescribers

Ensure that prescriptions are issued promptly and accurately. Respond immediately to any reported prescription delays.

8.2 Clinical and Governance Team

Monitor prescription processing and delivery performance. Investigate and resolve prescription issues. Implement corrective actions as needed.

8.3 Signature RX and Partner Pharmacies

Ensure timely processing and delivery of prescriptions. Communicate promptly with BrightPath Neuro if a delay occurs.

9. Review

This policy will be reviewed annually or sooner if there are changes to legislation or operational requirements.

Medication Adjustment and Titration Policy

1. Purpose

This policy establishes the procedures for adjusting and titrating medications at BrightPath Neuro to ensure that patients receive safe and effective treatment tailored to their clinical needs. It sets out guidelines for initiating, adjusting, monitoring, and discontinuing medications to minimise side effects, improve clinical outcomes, and maintain patient safety. The purpose of this policy is to: Ensure that medication adjustments and titrations are conducted safely and systematically. Prevent medication errors and adverse drug reactions during adjustment or titration. Monitor patient response to changes in medication dosage. Ensure patient consent and understanding before making medication changes. Provide clear documentation and communication regarding medication changes.

2. Scope

This policy applies to all staff involved in the prescribing, monitoring, and management of medications at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Pharmacists (e.g., Signature RX)Nursing and Healthcare Staff, It covers: Controlled Drugs (CDs)Psychotropic medications (e.g., antidepressants, antipsychotics, mood stabilisers)Stimulant medications (e.g., methylphenidate, lisdexamfetamine)Anxiolytics and sedatives (e.g., benzodiazepines)Specialist medications (e.g., antiepileptics)

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that medication adjustments and titrations are performed in line with national clinical guidelines. Regularly reviewing medication regimens to optimise clinical outcomes. Monitoring patient response closely during medication changes. Involving patients in decisions about medication adjustments. Maintaining accurate documentation of all medication changes. Minimising the risk of withdrawal symptoms, side effects, or clinical deterioration during titration.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Medicines Act 1968Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001National Institute for Health and Care Excellence (NICE) Guidelines, General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)

5. Procedure

5.1 Principles of Medication Adjustment and Titration

Individualised Approach: Medication adjustments and titrations must be based on the patient’s: Clinical presentation, Medical history, Current medication regimen, Risk of side effects or drug interactions, Patient preference and consent,

Gradual Changes: Dosage changes should follow a “start low, go slow” approach where appropriate, especially for psychotropic medications. Adjustments should not exceed 25%–50% of the total daily dose unless clinically justified.

Minimum Effective Dose: The goal should be to achieve the minimum effective dose to manage symptoms while minimising side effects. If symptoms are well-managed, further dose increases should not be made.

Monitoring and Adjustment: Patient response must be closely monitored after any dose adjustment. Adverse effects, withdrawal symptoms, or lack of clinical improvement should prompt a reassessment.

5.2 Medication Initiation and Titration

Initial Dose Setting: The initial dose should be set according to: NICE guidelines, British National Formulary (BNF) recommendations, Patient weight, age, renal and hepatic function. For psychotropic medications, the lowest effective starting dose should be used. Titration Schedule: Titration schedules should be clearly documented in the patient’s clinical record. Typical titration increments should follow national guidelines (e.g., NICE).Example titration schedule for psychotropic medication: Start at 25% of target dose for 1 week, Increase to 50% of target dose for 2 weeks, Reassess after 2–4 weeks before further increases. Adjustments should only be made if there is a clear clinical need or insufficient symptom improvement. Controlled Drugs: Controlled drugs must be titrated more cautiously due to the risk of dependence and withdrawal. Controlled drug adjustments require additional monitoring and may require a slower titration schedule. Stimulants: Stimulant medications (e.g., methylphenidate) should follow a titration period of 4–6 weeks. Dose increases should be made at weekly intervals (or longer if clinically indicated).The target dose should be based on clinical response and side effect tolerance.

5.3 Medication Reduction and Discontinuation

Planned Reduction: Medication reduction should follow a gradual tapering process to avoid withdrawal effects. Dose reductions should not exceed 25% of the total dose every 1–2 weeks unless clinically indicated. For psychotropic medications, tapering periods should be longer to prevent relapse or withdrawal. Abrupt Discontinuation: Abrupt discontinuation should be avoided unless there is a serious adverse reaction or safety concern. If abrupt discontinuation is required, the patient should be closely monitored for withdrawal symptoms. Controlled Drugs: Controlled drugs should be reduced more cautiously to prevent withdrawal or rebound symptoms. A reduction rate of 5%–10% per week is generally recommended for controlled drugs. Emergency Discontinuation: In cases of severe side effects or medical emergencies (e.g., serotonin syndrome), medications should be stopped immediately. Immediate medical attention should be sought where necessary.

5.4 Monitoring and Oversight

Clinical Monitoring: Patients must be monitored for the following during titration or reduction: Symptom improvement, Side effects and adverse reactions, Withdrawal symptoms, Changes in mood, behaviour, or cognition, Monitoring should occur at the following intervals: Weekly for the first 4 weeks, Monthly after the first 4 weeks until stabilisation, Quarterly thereafter (or more frequently if clinically indicated)

Patient Communication:

Patients must be informed of potential side effects and withdrawal symptoms. Patients must be advised on how to seek help if they experience any adverse effects. Changes in medication must be explained clearly, including the rationale and expected outcomes.

Documentation:

All medication adjustments and titration plans must be documented in the patient’s clinical record. The following must be recorded: Initial dose and titration schedule, Patient response and side effects, Reason for any medication adjustments, Monitoring outcomes and next steps

5.5 Safeguarding and Risk Management

Patients at high risk of relapse, overdose, or medication non-compliance should have a personalised safety plan. Patients with a history of substance misuse or dependency must be monitored more frequently. Any signs of medication misuse, overuse, or self-harm must be reported to the Clinical Lead immediately.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of medication adjustments and titration records. Any deviations from national guidelines or prescribing protocols must be reviewed. Findings from audits will be reported to the Governance Lead and the Clinical Governance Committee. Staff performance in titration management will be reviewed through clinical supervision.

7. Training and Awareness

All prescribers must complete training on medication titration and adjustment. Training will include: Titration of psychotropic medications, Controlled drug regulations, Monitoring and managing side effects, Patient communication and consent, Annual refresher training will be provided.

8. Responsibilities

8.1 Prescribers

Ensure medication adjustments follow clinical guidelines. Monitor patient response and document all changes.

8.2 Clinical Lead

Provide oversight of medication titration plans.

8.3 Governance Team

Monitor compliance through audits and feedback.

9. Review

This policy will be reviewed annually or sooner if clinical guidelines or regulations change.

Patient Safeguarding and Risk Management Policy

1. Purpose

This policy establishes the framework for safeguarding and managing patient risk at BrightPath Neuro to ensure that all patients receive care and support in a safe and protective environment. It outlines the procedures for identifying, reporting, and responding to safeguarding concerns and managing patient risk to prevent harm. The purpose of this policy is to: Ensure that safeguarding principles are embedded into all clinical and operational activities. Protect patients from abuse, harm, neglect, and exploitation. Provide a clear process for identifying and responding to safeguarding concerns. Promote a culture of safety, openness, and transparency. Ensure that all staff are trained and competent in safeguarding and risk management.

2. Scope

This policy applies to all staff at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Governance Team, Nursing and Healthcare Staff, Administrative Staff, External Partners (e.g., Signature RX)It covers: Safeguarding vulnerable adults and children, Identifying and responding to abuse, neglect, or exploitation, Risk assessment and management of patient safety, Responding to allegations or concerns regarding staff or third parties, Compliance with statutory and professional safeguarding responsibilities

3. Policy Statement

BrightPath Neuro is committed to: Providing a safe and secure environment for all patients. Protecting patients from harm, abuse, and neglect. Responding promptly and effectively to safeguarding concerns. Promoting the rights, dignity, and autonomy of all patients. Ensuring that staff are trained and equipped to identify and respond to safeguarding risks. Maintaining confidentiality and respecting the privacy of patients while adhering to legal obligations. Working in partnership with external agencies (e.g., social services, police, and safeguarding boards).

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Children Act 1989 and 2004Care Act 2014Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Human Rights Act 1998Mental Capacity Act 2005General Data Protection Regulation (UK GDPR)Safeguarding Vulnerable Groups Act 2006Working Together to Safeguard Children (2018)NICE Guidelines, Care Quality Commission (CQC) Regulations, Local Safeguarding Adults and Children Boards’ Guidelines

5.Procedure

5.1 Safeguarding Principles

BrightPath Neuro is committed to upholding the six fundamental principles of safeguarding as set out in the Care Act 2014. These principles are as follows:

Empowerment, which involves supporting individuals to make their own decisions and provide informed consent; Prevention, which focuses on taking proactive measures to avoid harm or abuse; Proportionality, ensuring that responses to safeguarding concerns are appropriate and sensitive to the level of risk; Protection, which entails taking immediate and effective action to safeguard individuals from harm; Partnership, which emphasises collaboration with other agencies to prevent and respond to abuse; and Accountability, ensuring that all safeguarding practices are conducted transparently and with clear responsibility.

5.2 Identifying Safeguarding Concerns

Staff must be aware of the signs and symptoms of abuse, neglect, and exploitation, including:

5.2.1 Types of Abuse:

Abuse can take many forms, each with distinct characteristics and examples. Physical abuse includes actions such as hitting, slapping, kicking, the misuse of medication, and inappropriate restraint. Sexual abuse encompasses rape, sexual assault, harassment, and any form of non-consensual sexual contact. Emotional or psychological abuse involves threats, intimidation, humiliation, and bullying. Neglect and acts of omission refer to the failure to provide essential care, such as food, medical attention, or basic support. Financial abuse includes theft, fraud, and the misuse of an individual’s property or money. Domestic abuse may involve coercive control, physical violence, and threats within intimate or familial relationships. Modern slavery includes forced labour, human trafficking, and domestic servitude. Institutional abuse relates to substandard care practices, mismanagement of medication, and systemic neglect within care settings. Discriminatory abuse is abuse based on characteristics such as race, gender, age, or sexual orientation, including racism, sexism, ageism, and homophobia. Finally, self-neglect involves an individual’s failure to care for themselves, which may manifest as poor hygiene, malnutrition, or refusal of necessary care.

5.2.2 High-Risk Indicators:

Staff should be particularly alert to the following high-risk indicators: Changes in behaviour or emotional state (e.g., withdrawal, aggression)Unexplained injuries or bruising, Sudden changes in financial status, Fear of a caregiver or reluctance to discuss issues, Poor hygiene or malnutrition, Inappropriate or delayed medical attention

5.3 Responding to a Safeguarding Concern

If a safeguarding concern is identified, the following steps must be taken:

5.3.1 Immediate Action: Ensure the Patient’s Safety: Remove the patient from immediate danger (if applicable).Provide medical attention if required. Contact emergency services (999) if the patient is at immediate risk of harm.

Report the Concern: Report the safeguarding concern immediately to the Safeguarding Lead. Complete a Safeguarding Incident Report via the online reporting system within 24 hours.

5.3.2 Investigation:

The Safeguarding Lead will conduct an initial assessment within 24 hours. If the concern meets safeguarding thresholds, a formal safeguarding investigation will be initiated. The Safeguarding Lead will liaise with: Local Authority Safeguarding Teams, Police (if a crime is suspected)Clinical Lead, Social Services, The Safeguarding Lead will coordinate a safeguarding strategy meeting within 72 hours (if required).

5.3.3 Risk Assessment and Protection Plan:

A patient-specific Protection Plan will be developed within 5 working days. The Protection Plan will include: Identification of safeguarding risks. Actions required to protect the patient. Support services and care adjustments. Monitoring and review arrangements. The Protection Plan must be reviewed at least every 3 months or sooner if the patient’s condition changes.

5.3.4 Documentation:

All safeguarding incidents and protection plans must be logged in the patient’s clinical record. A Safeguarding Investigation Report must be completed within 10 working days. Documentation must be retained for 7 years from the date of the incident.

5.4 Multi-Agency Working

BrightPath Neuro will work in partnership with: Local Safeguarding Adults and Children Boards, Police, Social Services, Healthcare providers, Voluntary and community organisations.

6. Monitoring and Compliance

The Safeguarding Lead will conduct quarterly safeguarding audits. The Governance Lead will review safeguarding incidents and risk management reports. Lessons learned will be incorporated into staff training and policy updates. Safeguarding trends and outcomes will be reported to the Clinical Governance Committee.

7. Training and Awareness

All staff must complete safeguarding training annually. Safeguarding training will cover: Identifying abuse and neglect, Responding to safeguarding concerns, Legal responsibilities under the Care Act, Multi-agency working, Confidentiality and consent, Additional specialist safeguarding training will be provided to the Clinical and Safeguarding Leads.

8. Responsibilities

8.1 Safeguarding Lead

Oversee all safeguarding activity. Ensure compliance with safeguarding procedures.

8.2 Clinical Lead

Ensure that protection plans are implemented effectively. Review safeguarding incidents and outcomes.

8.3 Governance Lead

Ensure that safeguarding audits are completed and reported.

8.4 Staff

Report safeguarding concerns immediately. Follow the safeguarding procedure.

9. Review

This policy will be reviewed annually or sooner if safeguarding legislation or guidelines change.

Patient Confidentiality and Consent Policy

1. Purpose

This policy establishes the procedures for managing patient confidentiality and obtaining informed consent at BrightPath Neuro to ensure that patient information is handled securely and with respect for privacy. It also sets out the requirements for obtaining and documenting consent for treatment, information sharing, and data processing in line with legal and regulatory standards. The purpose of this policy is to: Ensure that all patient information is handled confidentially and securely. Provide a clear process for obtaining and documenting patient consent. Ensure that patients understand their rights regarding confidentiality and consent. Maintain compliance with legal and regulatory requirements for data protection and patient rights. Protect patient autonomy, dignity, and privacy.

2. Scope

This policy applies to all staff involved in the collection, storage, use, and sharing of patient information at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Governance Team, Administrative Staff, External Partners (e.g., Signature RX)It covers: Patient medical records and prescription records, Verbal and written communication with patients, Electronic health records and clinical documentation, Consent for treatment, medication, and data sharing, Disclosure of patient information to third parties, Data processing and storage

3. Policy Statement

BrightPath Neuro is committed to: Maintaining the highest standards of confidentiality in handling patient information. Ensuring that patients are fully informed about their treatment and data protection rights. Protecting patient data from unauthorised access, loss, or misuse. Ensuring that patients provide valid, informed consent for treatment and data sharing. Respecting patients’ decisions regarding their care and confidentiality. Ensuring that all staff are trained in confidentiality and consent requirements.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Data Protection Regulation (UK GDPR)Data Protection Act 2018Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Human Rights Act 1998Freedom of Information Act 2000Mental Capacity Act 2005Children Act 1989 and 2004NHS Confidentiality Code of Practice, Care Quality Commission (CQC) Regulations, National Institute for Health and Care Excellence (NICE) Guidelines

5. Procedure

5.1 Patient Confidentiality Access to Patient Information:

Only authorised staff involved in the patient’s care are permitted to access patient information. Access to patient information should be granted on a "need-to-know" basis only. Staff must use their unique login credentials to access patient records. Physical files should be stored in locked cabinets with restricted access.

Electronic Data Handling:

Patient information stored electronically must be encrypted and password protected. Patient information transmitted electronically (e.g., email) must be secured through encryption. Patient information stored on portable devices (e.g., laptops) must be protected by encryption and secure logins.

Verbal and Written Communication:

Patient information should not be discussed in public or open areas. Communication with patients should be conducted privately where possible. Phone calls regarding patient information should only be conducted in secure, private locations.

Third-Party Access:

Patient information should not be shared with third parties without the patient’s explicit consent unless required by law. Staff must verify the identity of the requesting party before disclosing any patient information.

Anonymisation and Redaction:

Where possible, patient information should be anonymised before use for research, audit, or training purposes. Any identifiable data should be redacted where not essential.

5.2 Consent for Treatment

Implied Consent:

Consent can be implied when a patient voluntarily engages with a healthcare professional for assessment or treatment. Example: A patient extending their arm for a blood test implies consent for the procedure.

Verbal Consent:

Verbal consent is required when explaining the purpose and potential side effects of a treatment or procedure. Example: A prescriber explaining the side effects of a new medication and the patient verbally agreeing.

Written Consent:

Written consent is required for: High-risk procedures (e.g., general anesthesia)Participation in clinical trials or research, Disclosure of sensitive information to third parties, Written consent must be signed and dated by the patient.

Capacity to Consent:

A patient must have the mental capacity to give valid consent. Capacity should be assessed using the criteria set out in the Mental Capacity Act 2005: The patient must understand the information provided. The patient must retain the information long enough to make a decision. The patient must be able to weigh up the information to make a decision. The patient must be able to communicate their decision.

Consent for Children and Young People:

Patients aged 16 or over are presumed to have the capacity to consent unless there is evidence to the contrary. For patients under 16, consent may be obtained if the patient is assessed to have sufficient maturity and understanding (Gillick Competence).If the patient is not deemed competent, parental or guardian consent is required.

Refusal of Consent:

A patient has the right to refuse consent for treatment. Staff must explain the potential consequences of refusal. Refusal of consent should be documented in the patient’s record. No treatment should be administered without the patient’s consent unless required under emergency or mental health legislation.

5.3 Consent for Data Sharing

Explicit Consent:

Patients must provide explicit consent for: Sharing information with third parties (e.g., another healthcare provider).Including information in research or training. Disclosing information to family members or carers.

Implied Consent:

Consent is implied for sharing information within the direct care team. Consent is implied for transferring information to the dispensing pharmacy (e.g., Signature RX).

Withdrawing Consent:

A patient may withdraw consent for data sharing at any time. Staff must respect the patient’s request and update records accordingly.

5.4 Breach of Confidentiality

Types of Breach:

Unauthorised access to patient information. Loss of physical or electronic patient records. Improper disposal of patient information. Disclosure of patient information without consent.

Reporting and Investigation:

All breaches of confidentiality must be reported to the Data Protection Officer (DPO) within 24 hours. A full investigation must be completed within 5 working days. Breaches involving controlled drugs must be reported to the Clinical Lead and Governance Lead. Breaches involving a data loss affecting more than 500 individuals must be reported to the ICO within 72 hours.

Corrective Action:

Staff involved in a breach will receive retraining if required. Systemic issues contributing to the breach will be addressed through corrective action.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of patient consent and data protection practices. All breaches of confidentiality and consent errors will be reviewed by the Clinical Governance Committee. Staff compliance with consent and confidentiality requirements will be monitored through supervision and annual performance reviews.

7. Training and Awareness

All staff must complete annual training on: Data protection and confidentiality, Informed consent, Handling and processing patient information,

Refresher training will be provided annually or when changes to legislation occur.

8. Responsibilities

8.1 Data Protection Officer (DPO)

Oversee compliance with data protection and confidentiality laws.

8.2 Clinical Lead

Ensure that consent processes meet clinical and legal standards.

8.3 Staff

Maintain patient confidentiality at all times. Obtain informed consent where required.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Staff supervision Policy

1. Purpose

This policy sets out the framework for staff supervision at BrightPath Neuro to ensure that all staff receive consistent and effective guidance, support, and professional development. It establishes clear guidelines for the frequency, structure, and documentation of staff supervision to enhance performance, ensure compliance with professional standards, and support staff well-being. The purpose of this policy is to: Provide a structured approach to staff supervision. Support staff development and competency in clinical and non-clinical roles. Identify and address performance issues promptly. Promote reflective practice and continuous improvement. Ensure staff feel supported in their roles and have opportunities to raise concerns.

2. Scope

This policy applies to all staff employed by BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Nursing and Healthcare Staff, Administrative Staff, Governance and Compliance Teams, Partner Organisations (if applicable)It covers: Clinical supervision, Managerial supervision, Reflective practice, Performance management, Professional development

3. Policy Statement

BrightPath Neuro is committed to: Providing high-quality supervision for all staff. Ensuring that supervision is supportive, structured, and consistent. Promoting a learning culture that encourages reflection and professional growth. Identifying and addressing barriers to performance and well-being. Ensuring that supervision supports compliance with professional standards and regulatory requirements.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, British Psychological Society (BPS) Guidelines, National Health Service (NHS) Leadership Academy Standards

5. Procedure

5.1 Types of Supervision

BrightPath Neuro offers a range of supervision types to support staff in their roles. These include clinical supervision, held monthly by a Clinical Lead or Senior Practitioner, focusing on patient care, clinical decision-making, and professional development; managerial supervision, also monthly, led by a Line Manager or Department Head to address performance and operational matters; and reflective supervision, held every six weeks to support staff in exploring their emotional well-being and practice. Safeguarding supervision occurs every three months, or more frequently if needed, led by the Safeguarding Lead to guide staff in managing high-risk cases. Peer supervision takes place quarterly and is facilitated by a Senior Practitioner, providing a collaborative space to share experiences. Finally, professional development supervision is conducted annually by the Line Manager or Training Lead, focusing on skills development and career progression.

5.2 Clinical Supervision

Purpose:

To review patient care, clinical decision-making, and adherence to guidelines. To identify areas of clinical improvement. To provide support in handling complex clinical cases.

Process:

Clinical supervision should be scheduled monthly. The session should focus on: Clinical cases and decision-making. Medication management and titration. Risk assessment and safeguarding issues. Professional conduct and patient interactions.

Documentation:

Clinical supervision must be documented in the staff member’s supervision file. Key decisions and action points should be recorded. Confidentiality must be maintained unless there is a safeguarding or safety issue.

5.3 Managerial Supervision

Purpose:

To review staff performance and workload. To provide support and address performance issues. To ensure compliance with organisational policies and standards.

Process:

Managerial supervision should be scheduled monthly. The session should focus on: Staff workload and capacity. Time management and task completion. Organisational compliance and incident reporting. Staff well-being and support needs.

Documentation:

Managerial supervision must be recorded in the staff member’s performance file. Action points and follow-up tasks should be clearly defined.

5.4 Reflective Supervision

Purpose:

To provide staff with a space to reflect on their experiences and emotions. To prevent burnout and support emotional well-being. To encourage learning from both positive and negative experiences.

Process:

Reflective supervision should be held every 6 weeks. The session should focus on: Challenges in practice. Ethical dilemmas. Emotional responses to work. Learning points for future practice.

Documentation:

Reflective supervision notes should be stored confidentially. Staff should be encouraged to keep personal reflective logs.

5.5 Safeguarding Supervision

Purpose:

To support staff in managing safeguarding cases. To review the effectiveness of safeguarding plans. To provide emotional support to staff involved in complex cases.

Process:

Safeguarding supervision should be held every 3 months or more frequently if required. The session should focus on: Open safeguarding cases. Professional responsibility and escalation. Legal and procedural requirements. Emotional impact of managing safeguarding cases.

Documentation:

Safeguarding supervision notes must be recorded in the safeguarding file. All actions and follow-ups must be clearly defined.

5.6 Professional Development Supervision

Purpose:

To support career progression and training. To identify learning and development needs. To review training compliance and CPD hours.

Process:

Professional development supervision should be held annually. The session should focus on: Skills and knowledge gaps. CPD and training requirements. Career progression opportunities.

Documentation:

Professional development plans must be recorded in the staff file. Follow-up actions should be scheduled and monitored.5.7 Feedback and Escalation, Staff should have the opportunity to provide feedback on the supervision process. Issues raised in supervision should be escalated to the Clinical Lead or Governance Lead if: The staff member’s performance is consistently below standard. Safeguarding or patient safety issues are identified. Professional misconduct or regulatory breaches are identified.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of supervision records. Compliance with supervision schedules and documentation requirements will be monitored. On-compliance with supervision requirements will be addressed through performance management.

7. Training and Awareness

All supervisors must complete training on effective supervision techniques. Supervisors will receive annual refresher training on: Clinical decision-making, Managing performance and conduct, Supporting emotional well-being, Professional and ethical standards

8. Responsibilities

8.1 Clinical Lead

Oversee the clinical supervision process. Ensure clinical supervision aligns with professional standards.

8.2 Governance Lead

Monitor compliance with supervision requirements. Provide guidance on professional standards.

8.3 Line Managers

Ensure managerial supervision is conducted regularly. Address performance and conduct issues.

8.4 Staff

Engage actively in supervision sessions. Complete any required actions from supervision.

9. Review

This policy will be reviewed annually or sooner if regulatory or operational changes occur.

Controlled Drugs (CD) Training and Competency Policy

1. Purpose

This policy sets out the training and competency requirements for the prescribing, monitoring, and governance of controlled drugs (CDs) at BrightPath Neuro. While BrightPath Neuro does not handle, administer, store, or dispose of controlled drugs, it is essential that staff involved in the prescribing and monitoring of controlled drugs understand the legal and professional standards involved. The purpose of this policy is to: Ensure that all staff involved in the prescribing and monitoring of controlled drugs have the appropriate knowledge and competency. Ensure compliance with national legislation and professional guidelines. Maintain high standards of clinical governance related to controlled drugs. Ensure that staff are aware of their responsibilities when working with pharmacy partners (e.g., Signature RX).Establish a clear framework for prescribing and monitoring controlled drugs.

2. Scope

This policy applies to all staff involved in the prescribing and clinical management of controlled drugs at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Pharmacists (in collaboration with Signature RX)Administrative and Governance Staff, It covers: Prescribing of controlled drugs, Monitoring of controlled drug use, Clinical oversight of controlled drug treatment, Communication with pharmacy partners (e.g., Signature RX)Incident reporting and investigation

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that staff involved in the prescribing and monitoring of controlled drugs receive appropriate training and assessment. Working closely with Signature RX to ensure that controlled drugs are handled, stored, and disposed of in line with national standards. Providing staff with the skills and knowledge to prescribe and monitor controlled drugs safely and effectively. Preventing misuse, diversion, and medication errors involving controlled drugs. Ensuring that all prescribing and monitoring activities comply with national legislation and professional standards.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, Royal Pharmaceutical Society Guidelines, British National Formulary (BNF)

5. Procedure

5.1 Controlled Drug Classification

Controlled drugs are classified under the Misuse of Drugs Regulations 2001 into five schedules based on their potential for misuse and harm:

Schedule 1 drugs, such as LSD and cannabis, have no recognised medicinal use and require a Home Office license for research. Schedule 2 drugs, including morphine, oxycodone, and fentanyl, have a high potential for abuse and require secure storage, meticulous record-keeping, and a witness for their destruction. Schedule 3 drugs, such as buprenorphine and tramadol, present a moderate risk and require secure storage, though a controlled drug register is not necessary. Schedule 4 drugs, like diazepam and clonazepam, have a lower potential for abuse and do not require special storage or record-keeping. Schedule 5 drugs, including codeine and pholcodine, are considered to have the lowest potential for misuse and may be available over the counter with certain restrictions. All storage, handling, and disposal of controlled drugs are managed by Signature RX in accordance with the Misuse of Drugs Regulations 2001.

5.2 Staff Training Requirements

Induction Training:

All staff involved in prescribing or monitoring controlled drugs must complete induction training within 4 weeks of starting employment. Induction training must cover: Legal classification and schedules of controlled drugs. Prescribing requirements. Communication and collaboration with Signature RX. Monitoring and reporting responsibilities.

Mandatory Controlled Drugs Training:

All staff involved in prescribing and monitoring controlled drugs must complete controlled drugs training annually. Training should be provided by an experienced Clinical Lead or Pharmacist. Training must cover: Safe prescribing of controlled drugs, Communication with Signature RX monitoring for misuse and adverse effects, Reporting incidents and non-compliance, Legal and professional responsibilities

Specialist Training:

Staff involved in complex medication regimens (e.g., pain management) must complete specialist training every 2 years. Specialist training should include: Pain management protocols, Titration and withdrawal of opioids, Managing polypharmacy risks, Identifying medication misuse and dependency

5.3 Competency Assessment

Initial Competency Assessment:

All staff involved in prescribing and monitoring controlled drugs must complete a competency assessment within 4 weeks of completing training. Competency assessment must be conducted by a Clinical Lead or Senior Practitioner. Staff must demonstrate: Knowledge of controlled drug schedules, Correct prescribing practices, Communication with pharmacy partners, Monitoring for adverse effects and misuse,

Ongoing Competency Assessment:

Competency assessments must be repeated annually for staff involved in prescribing and monitoring controlled drugs. Competency should be reviewed through: Direct observation, Audit of prescribing records, Incident review and response,

Failure to Demonstrate Competency:

Staff who fail to demonstrate competency will be: Provided with additional training and support. Required to complete a repeat competency assessment within 4 weeks. If competency is not demonstrated after retraining, the issue will be escalated to the Clinical Lead and Governance Lead.

5.4 Prescribing of Controlled Drugs

Controlled drug prescriptions must: Follow the requirements of the Misuse of Drugs Regulations 2001.Include: Drug name, strength, and formulation, Total quantity (in both figures and words)Dosage instructions, Prescriber’s full name, registration number, and signature, Be recorded electronically using Signature RX systems. Be transmitted securely to Signature RX within 24 hours of issue.

5.5 Monitoring and Communication with Signature RX

Signature RX Responsibilities:

Signature RX is responsible for the handling, storage, and disposal of controlled drugs. Any discrepancies or issues must be reported to BrightPath Neuro within 24 hours.

Monitoring by BrightPath Neuro:

BrightPath Neuro staff must monitor patient response to controlled drugs. Any signs of misuse, dependency, or adverse reactions must be reported to the Clinical Lead and Signature RX. Regular reviews of prescribing data will be conducted.

5.6 Incident Reporting

All controlled drug prescribing errors, discrepancies, or adverse events must be reported within 24 hours. A full investigation must be conducted for: Prescribing errors, Diversion or misuse of drugs, Adverse patient reactions

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of controlled drug prescribing records. All discrepancies or failures in compliance will be escalated to the Governance Lead. Lessons learned will be incorporated into staff training and policy updates.

7. Training and Awareness

All staff involved in prescribing and monitoring controlled drugs must complete training annually. Additional training will be provided following any serious incident or breach of policy.

8. Responsibilities

8.1 Clinical Lead

Oversee controlled drug training and competency assessment

8.2 Governance Lead

Ensure compliance with prescribing standards.

8.3 Signature RX

Handle, store, and dispose of controlled drugs.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Controlled Drugs (CD) Prescribing Policy

1. Purpose

This policy sets out the procedures and requirements for the prescribing of controlled drugs (CDs) at BrightPath Neuro to ensure that all prescribing practices are safe, legal, and compliant with national guidelines. Although BrightPath Neuro does not handle, store, administer, or dispose of controlled drugs, it is essential that prescribing practices meet the highest standards of clinical governance and legal compliance. All controlled drug prescriptions are processed through BrightPath Neuro’s partner, Signature RX, who is responsible for dispensing and managing controlled drugs. The purpose of this policy is to: Ensure that controlled drugs are prescribed safely and appropriately. Prevent misuse, addiction, and diversion of controlled drugs. Ensure that prescribing practices comply with legal and regulatory requirements. Establish clear procedures for monitoring patient response and addressing prescribing issues. Define the roles and responsibilities of prescribers and partner organisations.

2. Scope

This policy applies to all staff involved in the prescribing and monitoring of controlled drugs at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists (in collaboration with Signature RX)Clinical Leads, Governance and Compliance Teams, It covers: Prescribing of controlled drugs, Communication with Signature RX, Monitoring patient response to controlled drugs, Incident reporting and investigation

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all prescribing of controlled drugs is conducted in accordance with national legal and professional standards. Working in partnership with Signature RX to ensure that controlled drugs are handled, stored, and dispensed safely. Preventing misuse, overprescribing, and medication-related harm. Providing staff with appropriate training and guidance on controlled drug prescribing. Ensuring that all prescribing activities are accurately documented and monitored.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal Pharmaceutical Society Guidelines

5. Procedure

5.1 Controlled Drug Classification

Controlled drugs are categorised under the Misuse of Drugs Regulations 2001 into five schedules, reflecting their potential for misuse and harm. Schedule 1 drugs, such as LSD and cannabis, have no recognised medicinal use and cannot be prescribed except for research purposes under license. Schedule 2 drugs, including morphine, oxycodone, and fentanyl, carry a high risk of abuse and addiction; prescriptions must be written, signed, and dispensed within 28 days. Schedule 3 drugs, such as buprenorphine and tramadol, have a moderate risk and must also be prescribed in writing and dispensed within 28 days. Schedule 4 drugs, including diazepam and clonazepam, are considered to have a lower potential for abuse but follow the same 28-day dispensing rule. Schedule 5 drugs, such as codeine and pholcodine, present the lowest risk and are subject only to standard prescribing requirements. All controlled drugs are handled, stored, and dispensed by Signature RX in full compliance with the Misuse of Drugs Regulations 2001.

5.2 Authorised Prescribers

Only the following staff members at BrightPath Neuro are authorised to prescribe controlled drugs: Medical Practitioners registered with the General Medical Council (GMC).Non-Medical Prescribers (NMPs) with a valid prescribing qualification registered with the Nursing and Midwifery Council (NMC).Pharmacists registered with the General Pharmaceutical Council (GPhC) (in consultation with Signature RX).Prescribers must: Hold a valid registration with their professional body. Complete annual training on controlled drug prescribing. Maintain up-to-date knowledge of the British National Formulary (BNF) guidelines. Adhere to national and local prescribing protocols.

5.3 Prescribing Process

Assessment of Clinical Need: A comprehensive clinical assessment must be conducted before prescribing a controlled drug. The assessment must include: Patient’s medical history, Current medications, Risk of misuse or addiction, Potential drug interactions, Patient’s mental and physical health status, Patient Consent: Informed consent must be obtained before prescribing a controlled drug. The patient must understand: The benefits and risks of the medication, Potential for addiction or withdrawal, Alternative treatment options. The consent discussion must be documented in the patient’s clinical record. Issuing a Prescription: Prescriptions for Schedule 2 and 3 drugs must: Be written or electronically transmitted to Signature RX. Include: Drug name, strength, and formulation, Total quantity (in both figures and words)Dosage instructions, Prescriber’s full name, registration number, and signature, Prescriptions for Schedule 2 and 3 drugs are valid for 28 days from the date of issue. Transmission to Signature RX: Prescriptions must be transmitted electronically to Signature RX within 24 hours of issue. The original signed prescription must be sent to Signature RX within 72 hours (if required).

5.4 Monitoring and Review

Ongoing Monitoring: Patients prescribed controlled drugs must be reviewed: Every 4 weeks for Schedule 2 and 3 drugs. Every 12 weeks for Schedule 4 and 5 drugs. Monitoring should include: Symptom relief, Adverse reactions, Signs of misuse, dependence, or withdrawal, Dose Adjustments: Any dose adjustments must be clearly documented in the patient’s clinical record. Changes to prescriptions must be communicated to Signature RX within 24 hours. Prescribing Limits: Prescriptions for Schedule 2 and 3 drugs should not exceed a 30-day supply unless clinically justified. Long-term prescribing must be reviewed by the Clinical Lead every 3 months.

5.5 Controlled Drug Errors and Incidents

Reporting: All prescribing errors, discrepancies, or adverse drug reactions must be reported within 24 hours using the online incident reporting system. Serious incidents must be reported to the Care Quality Commission (CQC) within 72 hours. Investigation: A full investigation must be conducted for: Prescribing errors, Diversion or misuse of controlled drugs, Failure to comply with prescribing regulations, Corrective Actions: Prescribers involved in controlled drug incidents must: Complete additional training (if required).Undergo a prescribing competency review. Be referred to the Clinical Lead for further action if the issue is not resolved.

5.6 Communication with Signature RX

Signature RX is responsible for: Dispensing and delivery of controlled drugs. Managing controlled drug stock levels. Reporting discrepancies and concerns to BrightPath Neuro.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of controlled drug prescribing. The Clinical Lead will review prescribing patterns and incident reports. Any non-compliance will be addressed through additional training and performance reviews.

7. Training and Awareness

All staff involved in prescribing controlled drugs must complete training annually. Specialist training for high-risk medications will be provided every 2 years

8. Responsibilities

Clinical Lead, Oversee prescribing standards and compliance. Governance Lead, Monitor prescribing performance. Prescribers, Ensure safe and appropriate prescribing.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Controlled Drugs (CD) Administration Policy

1. Purpose

This policy establishes the procedures and guidelines for the administration of controlled drugs (CDs) prescribed through BrightPath Neuro. BrightPath Neuro does not handle, store, administer, or dispose of controlled drugs. All controlled drug administration is managed by our partner, Signature RX, or other authorised healthcare providers. However, BrightPath Neuro remains responsible for ensuring that the administration of controlled drugs follows legal, professional, and clinical standards. The purpose of this policy is to: Ensure that controlled drugs are administered safely and appropriately. Ensure that patient response to controlled drugs is monitored and documented. Clarify the roles and responsibilities of BrightPath Neuro and Signature RX in controlled drug administration. Provide staff with guidance on responding to administration issues and adverse effects. Ensure compliance with legal and professional standards for controlled drug administration.

2. Scope

This policy applies to all staff involved in the prescribing, monitoring, and clinical oversight of controlled drug administration at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists (in collaboration with Signature RX)Clinical Leads, Governance and Compliance Teams, It covers: Monitoring and oversight of controlled drug administration, Managing patient response to controlled drugs, Reporting and investigating administration errors, Communicating with Signature RX regarding controlled drug administration

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that controlled drug administration complies with legal and professional standards. Working with Signature RX to ensure that controlled drugs are administered safely and appropriately. Monitoring patient response to controlled drugs and addressing any issues promptly. Preventing misuse, over-administration, and medication-related harm. Providing staff with appropriate training and guidance on controlled drug administration.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal Pharmaceutical Society Guidelines

5. Procedure

5.1 Controlled Drug Classification

Controlled drugs are categorised under the Misuse of Drugs Regulations 2001 into five schedules, reflecting their potential for misuse and harm. Schedule 1 drugs, such as LSD and cannabis, have no recognised medicinal use and cannot be prescribed except for research purposes under license. Schedule 2 drugs, including morphine, oxycodone, and fentanyl, carry a high risk of abuse and addiction; prescriptions must be written, signed, and dispensed within 28 days. Schedule 3 drugs, such as buprenorphine and tramadol, have a moderate risk and must also be prescribed in writing and dispensed within 28 days. Schedule 4 drugs, including diazepam and clonazepam, are considered to have a lower potential for abuse but follow the same 28-day dispensing rule. Schedule 5 drugs, such as codeine and pholcodine, present the lowest risk and are subject only to standard prescribing requirements. All controlled drugs are handled, stored, and dispensed by Signature RX in full compliance with the Misuse of Drugs Regulations 2001.

5.2 Administration of Controlled Drugs

Authorised Administrators: Controlled drugs can only be administered by: Registered Medical Practitioners, Non-Medical Prescribers (NMPs)Registered Nurses or Pharmacists (via Signature RX)BrightPath Neuro staff are not authorised to administer controlled drugs directly. Administration is performed by Signature RX or the patient's designated healthcare provider. Administration Requirements: Controlled drugs must be administered in line with: Prescribing instructions, Legal requirements (Misuse of Drugs Regulations 2001)Professional codes of practice (GMC, NMC, GPhC)Any deviation from the prescription must be reported immediately to the Clinical Lead. Witnessing Administration: Administration of Schedule 2 controlled drugs must be witnessed by a second healthcare professional. The witnessing professional must confirm: Patient identity, Correct dosage and route of administration, Expiry date of the medication, Proper disposal of any remaining medication (managed by Signature RX)Patient Identification: The patient must be positively identified before administering any controlled drug. Acceptable identification methods include: Full name and date of birth, Hospital or clinic ID, Verbal confirmation by the patient or caregiver

5.3 Monitoring and Patient Response

Immediate Monitoring: The patient’s response must be monitored for 30 minutes after administration of a controlled drug. Monitoring should include: Vital signs (blood pressure, heart rate, respiratory rate)Level of sedation, Presence of adverse reactions, Pain or symptom relief, Ongoing Monitoring: Patients receiving long-term controlled drug treatment must be monitored at regular intervals: Every 4 weeks for Schedule 2 and 3 drugs, Every 12 weeks for Schedule 4 and 5 drugs, Monitoring should assess: Clinical effectiveness, Side effects and tolerance, Signs of misuse or dependency, Reporting Adverse Reactions: Any adverse reaction or lack of therapeutic effect must be reported to the Clinical Lead and Signature RX within 24 hours. The prescribing practitioner must review the treatment plan within 48 hours.

5.4 Communication with Signature RX

Coordination: All controlled drug administration is coordinated with Signature RX. Signature RX is responsible for: Storing, handling, and dispensing controlled drugs, Managing medication stock levels, Disposal of unused controlled drugs, Documentation: Signature RX must maintain detailed records of all controlled drug administration. Administration records must include: Date and time of administration, Name of the administering professional, Drug name, strength, and formulation, Route of administration, Patient response and any side effects, BrightPath Neuro staff may request access to these records for clinical monitoring purposes.

5.5 Incident Reporting

Medication Errors: Any controlled drug administration error must be reported within 24 hours using the online incident reporting system. Examples of errors include: Incorrect dose or route of administration, Incorrect patient identification, Missed or delayed administration, Serious Incidents: Serious incidents (e.g., overdose, adverse reaction) must be escalated to the Clinical Lead immediately. A full investigation must be completed within 5 working days. Any serious incident must be reported to the Care Quality Commission (CQC) within 72 hours (if required).Misuse and Diversion: Any suspected misuse or diversion of controlled drugs must be reported immediately. The Clinical Lead will work with Signature RX to investigate and address the issue.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of controlled drug administration practices (in partnership with Signature RX).The Clinical Lead will review patient response and prescribing patterns. Any deviation from controlled drug administration standards will be addressed through additional training and policy updates.

7. Training and Awareness

All staff involved in prescribing and monitoring controlled drug administration must complete annual training on: Legal and clinical requirements, Monitoring and reporting responsibilities, Managing adverse effects and errors

8. Responsibilities

Clinical Lead, Oversee controlled drug administration standards and compliance. Governance Lead, Monitor performance and incident reporting. Signature RX, Manage administration and disposal of controlled drugs.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Controlled Drugs (CD) Security and Safe Custody Policy

1. Purpose

This policy sets out the procedures and requirements for the security and safe custody of controlled drugs (CDs) prescribed through BrightPath Neuro. BrightPath Neuro does not handle, store, administer, or dispose of controlled drugs. All controlled drug security, handling, and disposal are managed by our partner, Signature RX, in compliance with national legal and professional standards. The purpose of this policy is to: Ensure that controlled drugs prescribed through BrightPath Neuro are stored, handled, and secured in line with legal and professional standards. Ensure that staff involved in prescribing and monitoring controlled drugs understand their responsibilities regarding controlled drug security. Prevent theft, misuse, and diversion of controlled drugs. Ensure clear communication and coordination with Signature RX regarding the security and handling of controlled drugs. Maintain high standards of clinical governance and regulatory compliance.

2. Scope

This policy applies to all staff involved in the prescribing and monitoring of controlled drugs at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists (in collaboration with Signature RX)Clinical Leads, Governance and Compliance Teams, It covers: Security and storage of controlled drugs, Communication with Signature RX, Incident reporting and investigation related to controlled drug security, Legal and professional responsibilities for controlled drug security

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that controlled drugs are prescribed and managed in accordance with legal and professional standards. Working with Signature RX to ensure that controlled drugs are stored, handled, and disposed of securely. Preventing unauthorised access, theft, and misuse of controlled drugs. Ensuring that staff understand their responsibilities for controlled drug security. Responding promptly and effectively to any security breach involving controlled drugs.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal Pharmaceutical Society Guidelines

5. Procedure

5.1 Controlled Drug Classification

Controlled drugs are categorised under the Misuse of Drugs Regulations 2001 into five schedules, reflecting their potential for misuse and harm. Schedule 1 drugs, such as LSD and cannabis, have no recognised medicinal use and cannot be prescribed except for research purposes under license. Schedule 2 drugs, including morphine, oxycodone, and fentanyl, carry a high risk of abuse and addiction; prescriptions must be written, signed, and dispensed within 28 days. Schedule 3 drugs, such as buprenorphine and tramadol, have a moderate risk and must also be prescribed in writing and dispensed within 28 days. Schedule 4 drugs, including diazepam and clonazepam, are considered to have a lower potential for abuse but follow the same 28-day dispensing rule. Schedule 5 drugs, such as codeine and pholcodine, present the lowest risk and are subject only to standard prescribing requirements. All controlled drugs are handled, stored, and dispensed by Signature RX in full compliance with the Misuse of Drugs Regulations 2001.

5.2 Responsibilities for Controlled Drug Security

Prescribers: Ensure that controlled drug prescriptions are accurate, complete, and compliant with prescribing guidelines. Confirm that prescriptions for Schedule 2 and Schedule 3 drugs are transmitted securely to Signature RX. Ensure that patient information and prescribing records are handled securely and confidentially. Signature RX: Responsible for: Storing, securing, and handling controlled drugs. Maintaining controlled drug stock records. Managing access to controlled drugs. Ensuring secure transportation of controlled drugs. Managing the disposal of controlled drugs. Clinical Lead: Ensure that prescribers adhere to controlled drug prescribing protocols. Provide guidance to staff on controlled drug prescribing and security standards. Respond to and investigate any reports of security breaches or misuse. Governance Lead: Conduct audits of controlled drug prescribing records and security protocols. Ensure that any security incidents are reported and investigated. Report serious security breaches to the Care Quality Commission (CQC).

5.3 Storage and Safe Custody of Controlled Drugs

Controlled drug storage and security are the responsibility of Signature RX. Storage Requirements (by Signature RX):Schedule 2 and 3 controlled drugs must be stored in a: Locked cabinet or safe that meets UK security standards. Cabinet or safe that is bolted to a wall or secured to the floor. The storage unit must be resistant to forced entry and comply with Home Office regulations. Access to the storage unit must be restricted to authorised staff only. Access Control: Signature RX must maintain a record of all staff with access to controlled drugs. A named person must be responsible for controlled drug security and stock checks. Keyholding must be limited to authorised staff only. Keys to controlled drug storage units must be stored securely when not in use. Controlled Drug Register: Signature RX must maintain a Controlled Drug Register in line with Misuse of Drugs Regulations 2001.The register must record: Date and time of issue or administration, Drug name, strength, and quantity, Patient details, Name of administering or dispensing professional, Remaining stock levels

5.4 Transport and Delivery of Controlled Drugs

Secure Transport: Controlled drugs must be transported in tamper-proof containers. Deliveries must be recorded in the Controlled Drug Register. Any loss of controlled drugs in transit must be reported immediately to the Clinical Lead and Governance Lead. Patient Collection: Patients collecting controlled drugs must present valid identification. Any uncollected controlled drugs must be returned to the secure storage unit.

5.5 Incident Reporting and Investigation

Security Breaches: Any security breach involving controlled drugs must be reported to the Clinical Lead and Governance Lead within 24 hours. Examples of security breaches include: Loss of controlled drugs, Theft or suspected diversion, Unauthorised access to controlled drugs, A full investigation must be conducted within 5 working days. Serious incidents must be reported to the Care Quality Commission (CQC) within 72 hours. Stock Discrepancies: Any stock discrepancy involving controlled drugs must be reported to Signature RX and the Clinical Lead. A reconciliation process must be conducted immediately. If theft or diversion is suspected, the issue must be escalated to the Governance Lead and the police (if required).Misuse or Diversion: Any suspicion of controlled drug misuse or diversion must be reported to the Clinical Lead immediately. A full investigation must be conducted within 5 working days.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of controlled drug prescribing records and security protocols. The Clinical Lead will review prescribing practices and incident reports. Findings from audits and incident investigations will be reported to the Clinical Governance Committee.

7. Training and Awareness

All staff involved in controlled drug prescribing and monitoring must complete annual training on: Controlled drug classification and legal requirements, Prescribing and monitoring protocols, Reporting and managing security breaches

8. Responsibilities

Clinical Lead, Oversee compliance with prescribing and security protocols. Governance Lead, Ensure proper reporting and monitoring of security incidents. Signature RX, Ensure secure storage, handling, and disposal of controlled drugs.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Controlled Drugs (CD) Requisitioning Policy

1. Purpose

This policy sets out the procedures and requirements for the requisitioning of controlled drugs (CDs) prescribed through BrightPath Neuro. BrightPath Neuro does not handle, store, administer, or dispose of controlled drugs. All controlled drug requisitioning, storage, and supply are managed by our partner, Signature RX. However, BrightPath Neuro remains responsible for ensuring that requisitioning practices meet the highest standards of clinical governance and comply with legal and professional requirements. The purpose of this policy is to: Ensure that all controlled drug requisitions are managed in accordance with legal and professional guidelines. Establish clear procedures for prescribing and requisitioning controlled drugs through Signature RX. Prevent unauthorised access, misuse, and diversion of controlled drugs. Ensure that staff involved in the prescribing and requisitioning of controlled drugs are trained and competent. Maintain high standards of record-keeping and monitoring for controlled drug requisitions.

2. Scope

This policy applies to all staff involved in the prescribing and requisitioning of controlled drugs at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists (in collaboration with Signature RX)Clinical Leads, Governance and Compliance Teams, It covers: Prescribing and requisitioning of controlled drugs, Communication with Signature RX regarding requisitions, Legal and professional requirements for controlled drug requisitions, Incident reporting and investigation related to requisitioning

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that controlled drug requisitions are made safely and appropriately. Preventing misuse, diversion, and medication errors involving controlled drugs. Working with Signature RX to ensure that controlled drugs are requisitioned and supplied in line with national guidelines. Providing staff with the training and support required to carry out controlled drug requisitions safely. Ensuring that all controlled drug requisitioning activities are accurately documented and monitored.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal Pharmaceutical Society Guidelines

5. Procedure

5.1 Controlled Drug Classification

Controlled drugs are categorised under the Misuse of Drugs Regulations 2001 into five schedules, reflecting their potential for misuse and harm. Schedule 1 drugs, such as LSD and cannabis, have no recognised medicinal use and cannot be prescribed except for research purposes under license. Schedule 2 drugs, including morphine, oxycodone, and fentanyl, carry a high risk of abuse and addiction; prescriptions must be written, signed, and dispensed within 28 days. Schedule 3 drugs, such as buprenorphine and tramadol, have a moderate risk and must also be prescribed in writing and dispensed within 28 days. Schedule 4 drugs, including diazepam and clonazepam, are considered to have a lower potential for abuse but follow the same 28-day dispensing rule. Schedule 5 drugs, such as codeine and pholcodine, present the lowest risk and are subject only to standard prescribing requirements. All controlled drugs are handled, stored, and dispensed by Signature RX in full compliance with the Misuse of Drugs Regulations 2001.

5.2 Authorised Prescribers

Only the following staff at BrightPath Neuro are authorised to request the requisitioning of controlled drugs through Signature RX: Medical Practitioners registered with the General Medical Council (GMC)Non-Medical Prescribers (NMPs) with a valid prescribing qualification, Pharmacists registered with the General Pharmaceutical Council (GPhC)Prescribers must have completed controlled drug prescribing and requisitioning training within the last 12 months. Prescribers are responsible for: Ensuring that controlled drug requisitions are clinically justified. Ensuring that requisition forms are completed accurately and in full. Complying with legal and professional standards for controlled drug requisitions.

5.3 Requisition Process

Prescribing and Approval: A comprehensive clinical assessment must be conducted before prescribing a controlled drug. Prescriptions must be documented in the patient’s clinical record. All requisitions must be approved by a designated prescriber before transmission to Signature RX. Completing the Requisition Form: Requisitions for Schedule 2 and Schedule 3 controlled drugs must be made using the official Controlled Drug Requisition Form. The requisition form must include: Patient’s full name and date of birth, Prescriber’s full name and professional registration number, Drug name, strength, and formulation, Total quantity (in figures and words)Dosage instructions, Date of requisition, Signature of the prescriber, Transmission to Signature RX: Requisition forms must be transmitted electronically or in hard copy to Signature RX within 24 hours of issue. Original signed requisition forms must be retained for a minimum of 2 years. Verification by Signature RX: Signature, RX will verify all requisition forms before processing. Any incomplete or incorrect requisition forms will be rejected. Signature RX will notify BrightPath Neuro of any rejected requisitions within 24 hours.

5.4 Controlled Drug Supply and Delivery

Supply from Signature RX: Signature RX will supply controlled drugs directly to the patient or healthcare provider. Supply records will be maintained by Signature RX and available to BrightPath Neuro on request. Delivery Requirements: Controlled drugs must be delivered using tamper-proof packaging. Deliveries must be documented in the Controlled Drug Register maintained by Signature RX. Any discrepancies or delivery failures must be reported to the Clinical Lead within 24 hours.

5.5 Record-Keeping and Audit

Record Requirements: All controlled drug requisitions must be recorded in the patient’s clinical record. The record must include: Date of requisition, Prescriber’s details, Drug name, strength, and quantity, Outcome of requisition (approved or rejected)Audit Requirements: The Governance Lead will conduct quarterly audits of controlled drug requisitions. Audit findings will be presented to the Clinical Governance Committee. Non-compliance with requisition protocols will be addressed through additional training and supervision.

5.6 Incident Reporting and Investigation

Reporting: Any discrepancy or error involving a controlled drug requisition must be reported within 24 hours. Serious incidents (e.g., fraudulent requisitions or drug diversion) must be reported to the Care Quality Commission (CQC) within 72 hours. Investigation: A full investigation must be conducted within 5 working days. Findings must be documented, and corrective actions must be implemented where appropriate. Corrective Actions: Staff involved in requisition errors will receive additional training. Recurrent errors may result in removal of prescribing and requisitioning privileges.

6. Monitoring and Compliance

The Governance Lead will monitor all controlled drug requisitions. Quarterly audit findings will be reviewed by the Clinical Governance Committee. Any non-compliance will be addressed through additional training and supervision.

7. Training and Awareness

All staff involved in prescribing and requisitioning controlled drugs must complete annual training on: Controlled drug classification and prescribing guidelines, Completing requisition forms, Managing requisition errors and discrepancies

8. Responsibilities

Clinical Lead, Oversee controlled drug requisitioning standards and compliance. Governance Lead, Monitor requisitioning performance and compliance. Signature RX Manage the supply and delivery of controlled drugs.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Controlled Drugs (CD) Transport Security and Safe Custody Policy

1. Purpose

This policy establishes the procedures and guidelines for the secure transport and safe custody of controlled drugs (CDs) prescribed through BrightPath Neuro. BrightPath Neuro does not handle, store, administer, or transport controlled drugs. All controlled drug transport, storage, and security are managed by our partner, Signature RX. However, BrightPath Neuro remains responsible for ensuring that controlled drugs prescribed through its services are transported and handled securely in compliance with national and professional standards. The purpose of this policy is to: Ensure that controlled drugs prescribed through BrightPath Neuro are transported securely and handled in accordance with legal and professional requirements. Clarify the roles and responsibilities of Signature RX and BrightPath Neuro in controlled drug transport and security. Prevent theft, diversion, and unauthorised access to controlled drugs during transport. Provide a framework for reporting and investigating controlled drug transport incidents. Ensure that patient safety and confidentiality are maintained during controlled drug transport.

2. Scope

This policy applies to all staff involved in the prescribing, monitoring, and clinical oversight of controlled drugs at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists (in collaboration with Signature RX)Clinical Leads, Governance and Compliance Teams, It covers: Transport and delivery of controlled drugs, Security requirements for controlled drug transport, Communication with Signature RX regarding transport security, Incident reporting and investigation related to controlled drug transport

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that controlled drugs are transported securely and in compliance with legal and professional standards. Preventing theft, diversion, and loss of controlled drugs during transport. Working with Signature RX to ensure that controlled drug transport is conducted using appropriate security measures. Responding promptly and effectively to any incidents involving controlled drug transport. Ensuring that staff are trained and aware of their responsibilities regarding controlled drug transport and security.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal Pharmaceutical Society Guidelines

5. Procedure

5.1 Controlled Drug Classification

Controlled drugs are categorised under the Misuse of Drugs Regulations 2001 into five schedules, reflecting their potential for misuse and harm. Schedule 1 drugs, such as LSD and cannabis, have no recognised medicinal use and cannot be prescribed except for research purposes under license. Schedule 2 drugs, including morphine, oxycodone, and fentanyl, carry a high risk of abuse and addiction; prescriptions must be written, signed, and dispensed within 28 days. Schedule 3 drugs, such as buprenorphine and tramadol, have a moderate risk and must also be prescribed in writing and dispensed within 28 days. Schedule 4 drugs, including diazepam and clonazepam, are considered to have a lower potential for abuse but follow the same 28-day dispensing rule. Schedule 5 drugs, such as codeine and pholcodine, present the lowest risk and are subject only to standard prescribing requirements. All controlled drugs are handled, stored, and dispensed by Signature RX in full compliance with the Misuse of Drugs Regulations 2001.

5.2 Transport Responsibilities

Prescribers at BrightPath Neuro: Responsible for ensuring that prescriptions for controlled drugs are accurate, complete, and legally compliant. Responsible for transmitting prescriptions securely to Signature RX. Responsible for communicating any specific transport or delivery instructions to Signature RX. Signature RX: Responsible for organising the transport and delivery of controlled drugs. Responsible for ensuring that transport complies with national legal and professional requirements. Responsible for maintaining security throughout the transport process. Responsible for resolving transport errors or discrepancies. Clinical Lead: Responsible for providing oversight of controlled drug prescribing and transport arrangements. Responsible for investigating any transport-related incidents. Governance Lead: Responsible for ensuring that controlled drug transport security complies with national guidelines. Responsible for conducting audits of controlled drug transport and security.

5.3 Secure Transport of Controlled Drugs

Tamper-Proof Packaging: All controlled drugs (Schedules 2 and 3) must be transported in sealed, tamper-proof containers. Containers must be clearly labelled with: Patient’s name and date of birth, Drug name, strength, and quantity, Date of transport, Prescriber’s details, Secure Transportation: Controlled drugs must be transported using: A secure medical courier service. A registered pharmacy vehicle fitted with GPS tracking (if available).A secure lockbox for high-risk medications (Schedule 2 and 3).Temperature Control: If temperature control is required, controlled drugs must be transported using temperature-regulated containers. The container must display a temperature range and be monitored during transport. Chain of Custody: A chain of custody form must be completed at each stage of transport. The form must record: Time of dispatch, Identity of the courier, Time of delivery, Confirmation of receipt by the patient or healthcare provider, A copy of the chain of custody form must be retained for 2 years. Direct to Patient Delivery: Signature RX must deliver controlled drugs directly to the patient or a registered healthcare provider. The recipient must provide valid identification upon delivery. The recipient must sign a delivery receipt confirming acceptance of the medication.

5.4 Failed Delivery Protocol

Missed Delivery: If a delivery cannot be completed, the medication must be: Returned to Signature RX’s secure facility. Logged as a failed delivery in the controlled drug register. The patient and prescribing practitioner must be notified within 24 hours. Incorrect Delivery: If the wrong medication is delivered, the courier must: Immediately secure the medication. Return the medication to Signature RX.A full incident report must be completed within 24 hours. Lost or Stolen Medication: Any suspected theft or loss of controlled drugs during transport must be reported to: Signature RX, Clinical Lead and Governance Lead at BrightPath Neuro, Care Quality Commission (if required)A full investigation must be completed within 5 working days.

5.5 Incident Reporting and Investigation

Reporting: All controlled drug transport incidents must be reported within 24 hours. Serious incidents (e.g., theft, diversion, or loss) must be reported to the Care Quality Commission (CQC) within 72 hours. Investigation: A full investigation must be conducted within 5 working days. The investigation should determine: Cause of the incident, Impact on patient safety, Any security breaches, Findings must be documented and shared with Signature RX and the Clinical Governance Committee. Corrective Actions: Corrective actions may include: Updating transport protocols, Retraining staff, Improving security measures, Persistent transport issues may result in contract review with Signature RX.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of controlled drug transport and security records. The Clinical Lead will review transport incidents and resolutions. Audit findings will be presented to the Clinical Governance Committee.

7. Training and Awareness

All staff involved in controlled drug prescribing and monitoring must complete annual training on: Controlled drug transport security standards, Chain of custody requirements, Incident reporting protocols

8. Responsibilities

Clinical Lead, Oversee transport security compliance. Governance Lead, Monitor transport incidents and compliance. Signature RX, Manage controlled drug transport and security.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Controlled Drugs (CD) Receipt, Destruction and Disposal Policy

1. Purpose

This policy sets out the procedures and requirements for the receipt, destruction, and disposal of controlled drugs (CDs) prescribed through BrightPath Neuro. BrightPath Neuro does not handle, store, administer, or dispose of controlled drugs. All controlled drug receipt, destruction, and disposal are managed by our partner, Signature RX, in accordance with national legal and professional standards. However, BrightPath Neuro remains responsible for ensuring that controlled drug receipt, destruction, and disposal follow legal and regulatory guidelines. This includes ensuring that all prescribing and monitoring activities meet the highest standards of clinical governance and professional responsibility. The purpose of this policy is to: Ensure that controlled drugs are received, destroyed, and disposed of safely and legally. Prevent misuse, diversion, and medication errors involving controlled drugs. Establish clear communication and procedures with Signature RX regarding receipt, destruction, and disposal. Provide a framework for monitoring controlled drug destruction and disposal activities. Ensure that all staff involved in prescribing and monitoring controlled drugs are aware of their responsibilities.

2. Scope

This policy applies to all staff involved in the prescribing and monitoring of controlled drugs at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists (in collaboration with Signature RX)Clinical Leads, Governance and Compliance Teams, It covers: Receipt of controlled drugs from Signature RX, Management of discrepancies upon receipt, Destruction and disposal of controlled drugs, Reporting and investigation of controlled drug handling issues

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that controlled drugs are received, destroyed, and disposed of in accordance with legal and professional standards. Working with Signature RX to prevent diversion, misuse, and medication errors. Providing staff with appropriate training and guidance on controlled drug receipt, destruction, and disposal. Responding promptly and effectively to any discrepancies or incidents involving controlled drug handling. Maintaining accurate records and conducting regular audits of controlled drug destruction and disposal.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal Pharmaceutical Society Guidelines

5. Procedure

5.1 Controlled Drug Classification

Controlled drugs are categorised under the Misuse of Drugs Regulations 2001 into five schedules, reflecting their potential for misuse and harm. Schedule 1 drugs, such as LSD and cannabis, have no recognised medicinal use and cannot be prescribed except for research purposes under license. Schedule 2 drugs, including morphine, oxycodone, and fentanyl, carry a high risk of abuse and addiction; prescriptions must be written, signed, and dispensed within 28 days. Schedule 3 drugs, such as buprenorphine and tramadol, have a moderate risk and must also be prescribed in writing and dispensed within 28 days. Schedule 4 drugs, including diazepam and clonazepam, are considered to have a lower potential for abuse but follow the same 28-day dispensing rule. Schedule 5 drugs, such as codeine and pholcodine, present the lowest risk and are subject only to standard prescribing requirements. All controlled drugs are handled, stored, and dispensed by Signature RX in full compliance with the Misuse of Drugs Regulations 2001.

5.2 Controlled Drug Receipt

Responsibility for Receipt: All controlled drugs are delivered directly to Signature RX or to the patient's healthcare provider. BrightPath Neuro staff are not involved in receiving controlled drugs. Signature RX is responsible for ensuring that all deliveries are recorded in the Controlled Drug Register. Verification of Delivery: Signature RX must verify that the delivered controlled drug matches the prescription. Verification should include: Drug name, strength, and formulation, Quantity (in figures and words)Prescribing practitioner’s name and registration number, Date and time of delivery, Any discrepancies must be reported to BrightPath Neuro within 24 hours. Receipt Acknowledgement: Signature RX must maintain a delivery receipt signed by the authorised person receiving the medication. The receipt must include: Date and time of delivery, Signature of the authorised person receiving the medication, Confirmation that the delivery matches the prescription

5.3 Controlled Drug Destruction and Disposal

Authorisation for Destruction: Controlled drugs can only be destroyed by: A licensed pharmacist (e.g., Signature RX)An authorised waste disposal contractor, A Controlled Drugs Accountable Officer (CDAO)Destruction of Schedule 2 and Schedule 3 drugs must be witnessed by a second registered healthcare professional. Methods of Destruction: Schedule 2 and 3 controlled drugs must be destroyed using an approved drug denaturing kit. Schedule 4 and 5 controlled drugs may be destroyed using general pharmaceutical waste procedures. Signature RX is responsible for ensuring that controlled drugs are rendered unusable before disposal. Documentation of Destruction: A Controlled Drug Destruction Record must be completed for all destroyed drugs. The record must include: Date and time of destruction, Drug name, strength, and quantity, Reason for destruction (e.g., expired, damaged)Name and signature of the person destroying the drug, Name and signature of the witnessing healthcare professional, Return of Unused Controlled Drugs: Patients should be advised to return any unused or expired controlled drugs to Signature RX. Signature RX is responsible for ensuring that any returned medication is recorded, secured, and destroyed following legal guidelines.

5.4 Incident Reporting and Investigation

Reporting: Any discrepancy, loss, or suspected theft of controlled drugs must be reported to: Signature RXClinical Lead at BrightPath Neuro, Governance Lead at BrightPath Neuro, Serious incidents must be reported to the Care Quality Commission (CQC) within 72 hours. Investigation: A full investigation must be conducted within 5 working days. The investigation should determine: Cause of the incident, Impact on patient safety, Potential security breaches, Findings must be documented and reported to the Clinical Governance Committee. Corrective Actions: Corrective actions may include: Updating receipt and destruction protocols, Retraining staff involved in prescribing and monitoring, Reviewing security measures at Signature RX

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of controlled drug receipt and destruction records. The Clinical Lead will review destruction and disposal incidents and resolutions. Audit findings will be presented to the Clinical Governance Committee.

7. Training and Awareness

All staff involved in prescribing and monitoring controlled drugs must complete annual training on: Legal and professional requirements for controlled drug receipt and destruction, Reporting procedures for controlled drug discrepancies, Security and safe handling of controlled drugs

8. Responsibilities

Clinical Lead, Oversee compliance with controlled drug destruction and disposal protocols. Governance Lead, Monitor receipt and disposal incidents and compliance. Signature RX, Manage controlled drug receipt, destruction, and disposal.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Policy (for ADHD)

1. Purpose

This policy establishes the procedures and guidelines for obtaining informed consent from patients (or their legal guardians) before conducting an ADHD assessment and initiating any prescribing related to ADHD treatment. BrightPath Neuro is committed to ensuring that patients and their families fully understand the nature of ADHD assessments, the potential benefits and risks of treatment, and their right to make informed decisions about their care. Informed consent is a critical component of ethical clinical practice and legal compliance. The purpose of this policy is to: Ensure that patients provide valid and informed consent for ADHD assessments and prescribing. Ensure that patients understand the potential benefits, risks, and alternatives of ADHD medications. Protect patient autonomy and ensure decisions are made without coercion. Provide clear documentation of consent before initiating ADHD assessment and treatment. Ensure compliance with legal and professional standards related to informed consent.

2. Scope

This policy applies to all staff involved in the assessment, diagnosis, and prescribing of ADHD medications at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists, Clinical Leads, Governance and Compliance Teams, It covers: Consent for ADHD assessments, Consent for prescribing ADHD medications, Documentation of informed consent, Withdrawal of consent, Capacity and decision-making considerations

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that patients (or their legal guardians) provide valid, informed consent before ADHD assessments and prescribing. Providing patients with clear, accurate, and comprehensive information about ADHD assessments and medications. Respecting the patient’s right to accept or refuse treatment. Protecting the confidentiality of the patient’s decisions and medical information. Ensuring that consent is obtained without coercion or undue influence. Ensuring that patients understand their right to withdraw consent at any time.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Medical Council (GMC) Consent Guidance, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Children Act 1989 and 2004Mental Capacity Act 2005Human Rights Act 1998National Institute for Health and Care Excellence (NICE) Guidelines, Nursing and Midwifery Council (NMC) Code of Conduct, British National Formulary (BNF)Care Quality Commission (CQC) Regulations

5. Procedure

5.1 Principles of Informed Consent

Voluntariness: Consent must be given voluntarily and without pressure, coercion, or undue influence. The patient (or their legal guardian) has the right to refuse or withdraw consent at any time. Capacity: The patient must have the capacity to understand and make decisions about their care. If the patient lacks capacity, consent must be obtained from a person with legal authority (e.g., parent, guardian, or power of attorney).Capacity should be assessed in line with the criteria outlined in the Mental Capacity Act 2005: Understanding of the information provided. Retention of the information long enough to make a decision. Ability to weigh the information to make a decision. Ability to communicate the decision. Disclosure: Patients (or their legal guardians) must be provided with clear and comprehensive information, including: Nature and purpose of the ADHD assessment. Benefits and risks of ADHD medication. Possible side effects and drug interactions. Alternative treatments (including non-pharmacological options).Right to refuse treatment without penalty. Documentation: Consent must be documented in the patient’s clinical record. The signed consent form must include: Patient's name and date of birth. Prescribing clinician's name and registration number. Statement confirming that the patient has received sufficient information and had the opportunity to ask questions. Patient's signature and date of signing.

5.2 Consent for ADHD Assessment

Initial Consent: Before conducting an ADHD assessment, the assessing clinician must: Explain the purpose, process, and duration of the assessment. Provide information about the potential outcomes of the assessment. Discuss the possibility of a confirmed or excluded diagnosis. Explain the confidentiality of the assessment process and how information will be used. Consent for Information Sharing: Consent must be obtained before sharing the patient’s assessment results with third parties (e.g., GP, school, or other healthcare providers).A separate consent form should be used for information sharing. Capacity to Consent: Patients aged 16 or over are presumed to have the capacity to consent unless evidence suggests otherwise. For patients under 16, consent may be obtained if the patient is assessed as having sufficient understanding and maturity (Gillick Competence).If the patient is not deemed competent, parental or guardian consent is required.

5.3 Consent for Prescribing ADHD Medication

Medication Overview:The prescribing clinician must explain the following to the patient (or legal guardian): Medication name, dosage, and administration schedule.Expected benefits of the medication.Common side effects and drug interactions.Potential risks (e.g., dependency, cardiovascular effects).Need for ongoing monitoring (e.g., blood pressure, weight).Procedure for adjusting or discontinuing the medication. Consent for Controlled Drugs: If prescribing a controlled drug (e.g., methylphenidate): Inform the patient about legal requirements for handling and storage. Inform the patient about potential misuse and dependency risks. Consent for controlled drugs must be documented using a specific Controlled Drug Consent Form. Ongoing Consent: Consent for ADHD medication must be reviewed: Every 12 months for patients on long-term treatment. Every 6 months if there are changes in medication or dosage. At any time if the patient’s clinical condition or capacity changes.

5.4 Withdrawal of Consent

Right to Withdraw: Patients have the right to withdraw consent for ADHD medication at any time. Withdrawal of consent should be documented in the patient’s record. Prescriber's Responsibility: If a patient withdraws consent for medication, the prescriber must: Review alternative treatment options. Discuss the risks of stopping medication (if applicable).Provide follow-up care as needed.

5.5 Documentation of Consent

Consent Form: The completed consent form must be filed in the patient’s clinical record. A copy of the consent form should be provided to the patient. Electronic Record: A scanned copy of the consent form must be uploaded to the patient’s electronic health record. Audit and Monitoring: The Governance Lead will audit consent documentation quarterly. Any discrepancies or missing documentation must be reported and addressed.

6. Monitoring and Compliance

The Clinical Lead will monitor consent practices through supervision and clinical audits. The Governance Lead will conduct quarterly audits of consent records. Non-compliance will be addressed through additional training and policy updates.

7. Training and Awareness

All staff involved in ADHD assessment and prescribing must complete annual training on: Legal and ethical principles of informed consent. Communicating risk and benefits. Documenting consent.

8. Responsibilities

Clinical Lead, Ensure compliance with consent protocols. Governance Lead, Monitor and audit consent practices. Prescribing Clinicians, Obtain and document informed consent.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (for ADHD)

1. Purpose

This policy establishes the procedures and guidelines for conducting initial assessments and screenings for Attention Deficit Hyperactivity Disorder (ADHD) at BrightPath Neuro. BrightPath Neuro is committed to providing high-quality, evidence-based assessments for individuals presenting with symptoms consistent with ADHD. The initial assessment and screening process aims to ensure accurate diagnosis, identify co-existing conditions, and develop an Individualised care plan based on the patient’s unique needs. The purpose of this policy is to: Ensure that ADHD assessments and screenings are conducted in accordance with evidence-based practice and national guidelines. Ensure that patients and their families understand the purpose and process of the ADHD assessment. Identify co-morbid conditions and differential diagnoses that may influence the diagnosis and treatment plan. Provide a clear framework for clinical decision-making during the ADHD assessment process. Ensure that patients provide valid and informed consent before initiating the assessment process.

2. Scope

This policy applies to all staff involved in the assessment, diagnosis, and prescribing of ADHD medications at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Leads, Governance and Compliance Teams, It covers: Initial screening for ADHD symptoms, Comprehensive clinical assessment for ADHD, Identification of co-morbid conditions and differential diagnoses, Documentation and communication of assessment outcomes, Consent and confidentiality during the assessment process

3. Policy Statement

BrightPath Neuro is committed to: Providing high-quality, evidence-based assessments for ADHD. Conducting ADHD assessments in a professional, respectful, and confidential manner. Ensuring that patients and their families understand the assessment process and consent to it. Identifying co-morbid conditions that may influence the diagnosis and treatment plan. Developing personalised treatment and support plans based on assessment findings. Ensuring compliance with legal and professional standards for ADHD assessment.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Medical Council (GMC) Professional Standards, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Children Act 1989 and 2004Mental Capacity Act 2005Human Rights Act 1998National Institute for Health and Care Excellence (NICE) Guidelines NG87Nursing and Midwifery Council (NMC) Code of Conduct, Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal College of Psychiatrists’ Standards for ADHD Assessment

5. Procedure

5.1 Principles of ADHD Assessment and Screening

Evidence-Based Practice: ADHD assessments at BrightPath Neuro must follow NICE Guidelines NG87.All assessments must be conducted by qualified professionals with experience in ADHD diagnosis. Patient-Centered Approach: The assessment process must consider the patient’s developmental, psychological, and social context. Assessments should be adapted to meet the communication and sensory needs of neurodivergent patients. Confidentiality: All information obtained during the assessment must be treated confidentially. Information may only be shared with the patient’s consent or when required by law. Informed Consent: Consent must be obtained from the patient (or legal guardian) before starting the assessment. Patients must understand the purpose and limitations of the assessment.

5.2 Pre-Assessment Process

Referral: ADHD assessments may be initiated following a referral from: General Practitioner (GP)School or educational setting, Self-referral by the patient or their family, Other healthcare professionals, Pre-Assessment Screening: The patient (or caregiver) must complete an ADHD screening questionnaire before the initial assessment. Screening tools may include: Conners’ Rating Scales, SNAP-IV Teacher and Parent Rating Scales, Adult ADHD Self-Report Scale (ASRS)Vanderbilt Assessment Scales, Screening results will be reviewed by the Clinical Lead to determine if further assessment is appropriate. Consent: Before starting the assessment, the clinician must: Explain the nature and purpose of the assessment. Discuss the potential outcomes of the assessment (e.g., diagnosis, referral).Explain the limitations of the assessment and the need for further testing if required. The patient (or legal guardian) must sign a Consent for ADHD Assessment Form. The completed consent form must be stored in the patient’s electronic health record.

5.3 Initial Assessment Process

Clinical Interview: The clinician must conduct a structured clinical interview covering: Patient’s developmental history, Family history of ADHD and other neurodevelopmental conditions, Current symptoms of inattention, hyperactivity, and impulsivity, Impact of symptoms on academic, occupational, and social functioning, Presence of co-morbid mental health or medical conditions, Behavioural and Cognitive Assessment: Standardised behavioural assessment tools should be used, including: Conners’ Comprehensive Behaviour Rating Scales (CBRS)Wechsler Intelligence Scale for Children (WISC)Test of Variables of Attention (TOVA)Continuous Performance Test (CPT)Results should be compared with developmental norms. Co-Morbid Condition Screening: The assessment must explore the presence of: Anxiety and depression, Autism Spectrum Condition (ASC)Sleep disorders, Learning difficulties (e.g., dyslexia)Oppositional Defiant Disorder (ODD)Conduct Disorder, School and Family Input: Where appropriate, the clinician should request input from: The patient’s school or educational setting, Parents or caregivers, Other healthcare professionals involved in the patient’s care

5.4 Outcome of Initial Assessment

Diagnosis: The clinician will reach one of the following conclusions: Confirmed diagnosis of ADHD, No diagnosis of ADHD, Inconclusive results (requiring further assessment)Identification of a different neurodevelopmental or mental health condition, Development of Treatment Plan: If ADHD is diagnosed, the clinician must: Develop a personalised treatment plan. Discuss options for medication and non-pharmacological interventions. Explain the need for regular monitoring and follow-up. Communication of Outcome: The clinician must explain the assessment outcome to the patient and their family. A written summary of the assessment and treatment plan must be provided to the patient. A copy of the assessment outcome must be shared with the patient’s GP (with consent).

5.5 Follow-Up and Monitoring

Initial Follow-Up: Patients diagnosed with ADHD must be reviewed within 4 weeks of starting treatment. The follow-up appointment should evaluate: Symptom improvement, Medication effectiveness and side effects, Psychological and behavioural response to treatment, Ongoing Monitoring: Patients should be reviewed at least every 12 months. Medication adjustments must be made based on clinical response.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of ADHD assessment records. The Governance Lead will monitor compliance with assessment protocols. Findings from audits will be reviewed at the Clinical Governance Committee.

7. Training and Awareness

All staff involved in ADHD assessments must complete annual training on: ADHD diagnostic criteria and guidelines, Use of standardised assessment tools, Legal requirements for informed consent

8. Responsibilities

Clinical Lead, Oversee the ADHD assessment process. Governance Lead, Monitor assessment practices and compliance. Assessing Clinicians, Conduct thorough and accurate ADHD assessments.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Data Protection and Confidentiality Policy

1. Purpose

This policy sets out the procedures and requirements for the handling, processing, storage, and sharing of personal and sensitive data at BrightPath Neuro. BrightPath Neuro is committed to maintaining the highest standards of confidentiality and data protection when handling patient, staff, and organisational data. This includes compliance with legal and professional requirements related to data protection, confidentiality, and information governance. The purpose of this policy is to: Ensure that personal and sensitive data are processed securely and confidentially. Protect patient and staff data from unauthorised access, loss, or misuse. Ensure compliance with data protection regulations and confidentiality laws. Provide clear guidelines on the secure handling and sharing of information. Ensure that patients’ and staff’s rights to privacy and confidentiality are respected.

2. Scope

This policy applies to all data and information collected, processed, stored, or shared by BrightPath Neuro, including but not limited to: Patient information,, Staff information, Financial and operational data, Clinical and health records, Electronic and paper-based records, It applies to all staff, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Administrative and Governance Staff, External Contractors and Partners (e.g., Signature RX)It covers: Data protection, Confidentiality of patient and staff information, Information sharing and data access, Secure storage and processing of data, Incident reporting and investigation

3. Policy Statement

BrightPath Neuro is committed to: Maintaining the confidentiality of all personal and sensitive data. Ensuring compliance with data protection and confidentiality legislation. Preventing unauthorised access, loss, or misuse of personal data. Providing staff with clear guidance on handling and protecting confidential information. Promoting a culture of accountability and transparency in data protection practices.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: UK General Data Protection Regulation (UK GDPR)Data Protection Act 2018Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Freedom of Information Act 2000Human Rights Act 1998Caldicott Principles (2013)Care Quality Commission (CQC) Regulations, NHS Confidentiality Code of Practice, ISO 27001 Information Security Standard

5. Procedure

5.1 Principles of Data Protection

BrightPath Neuro is committed to upholding the key principles of data protection in accordance with the UK General Data Protection Regulation (UK GDPR). These principles include lawfulness, fairness, and transparency, ensuring that personal data is processed in a lawful, fair, and open manner. Purpose limitation requires that data is collected only for specified, explicit, and legitimate purposes. Data minimisation ensures that only data which is adequate, relevant, and necessary is collected. The principle of accuracy demands that data is kept accurate and up to date, while storage limitation states that data should not be retained longer than necessary. Integrity and confidentiality require that data is processed securely to protect against unauthorised access, loss, or damage. Finally, accountability obliges BrightPath Neuro to demonstrate full compliance with data protection obligations at all times.

5.2 Patient and Staff Confidentiality

Definition of Confidential Information: Confidential information includes: Patient identifiable information (e.g., name, date of birth, health conditions)Staff personal details (e.g., address, employment history)Financial and operational data, Clinical notes and health records, Confidentiality applies to both electronic and paper-based records. Duty of Confidentiality: All staff have a legal and professional duty to maintain confidentiality. Staff must only access confidential information on a need-to-know basis. Patient information must not be disclosed to third parties without consent, unless legally required. Confidentiality Agreements: All staff must sign a confidentiality agreement upon employment. Breach of confidentiality may result in disciplinary action. Consent for Information Sharing: Patients must provide explicit consent for the sharing of their information with third parties (e.g., GPs, external healthcare providers).Consent must be documented in the patient’s clinical record.

5.3 Data Access and Processing

Access to Data: Access to patient and staff data is restricted to authorised staff only. Role-based access controls (RBAC) must be applied to limit data access. Access logs must be maintained and audited regularly. Processing of Data: Data must be processed in line with the UK GDPR. Processing includes collecting, recording, organising, and storing data. Data processing agreements must be in place with third-party providers. Data Minimisation: Only the minimum necessary data should be processed. Staff should avoid collecting excessive or unnecessary information.

5.4 Secure Storage and Handling of Data

Electronic Data: Patient records must be stored in secure, encrypted systems. Access to electronic data must be password-protected. Electronic records must be backed up regularly. Paper-Based Records: Paper records must be stored in locked cabinets. Access to paper records must be restricted to authorised staff. Paper records must be transported securely (e.g., sealed envelopes).Data Disposal: Electronic data must be securely deleted when no longer required. Paper records must be shredded or destroyed using confidential waste disposal.

5.5 Information Sharing

Patient Information Sharing: Information may only be shared with the patient’s consent, except when: There is a legal obligation to disclose. Disclosure is necessary to prevent harm to the patient or others. Disclosure is required for safeguarding purposes. External Providers: Data sharing agreements must be in place with third parties (e.g., Signature RX).Third parties must meet BrightPath Neuro’s data security requirements.

5.6 Data Breaches and Incidents

Definition of a Data Breach: A data breach includes: Loss or theft of confidential data, Unauthorised access to data, Disclosure of information to an unauthorised person, Loss or corruption of data, Reporting: All data breaches must be reported to the Data Protection Officer (DPO) within 24 hours. Serious data breaches must be reported to the Information Commissioner’s Office (ICO) within 72 hours. Investigation: A full investigation must be conducted within 5 working days. Findings must be documented, and corrective action must be taken. Corrective Actions: Staff involved in breaches may be required to complete additional training. Systemic issues identified during the investigation must be addressed through corrective action.

6. Monitoring and Compliance

The Data Protection Officer (DPO) will conduct quarterly audits of data protection and confidentiality practices. Compliance with data security protocols will be monitored through system access logs and incident reports. Non-compliance will be addressed through disciplinary action and additional training.

8. Responsibilities

Data Protection Officer (DPO)Oversee compliance with data protection legislation. Clinical Lead, Ensure patient data is handled securely and in line with guidelines. Governance Lead, Monitor and audit data protection and confidentiality practices.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Record Keeping and Documentation Policy

1. Purpose

This policy sets out the procedures and standards for the creation, maintenance, storage, and disposal of records at BrightPath Neuro. Accurate and secure record keeping is essential to ensure the delivery of high-quality care, maintain professional and legal standards, and support clinical decision-making. Clear and consistent documentation helps to ensure continuity of care, compliance with regulatory requirements, and effective clinical governance. The purpose of this policy is to: Ensure that all records created and maintained at BrightPath Neuro are accurate, complete, and secure. Define the standards for documenting clinical care, prescribing, and patient interactions. Ensure that records are retained, accessed, and disposed of in line with legal and regulatory requirements. Provide a framework for auditing and monitoring record-keeping practices. Ensure that patients’ rights to confidentiality and access to records are respected.

2. Scope

This policy applies to all records created, maintained, and stored at BrightPath Neuro, including but not limited to: Patient health records, Prescribing and medication records, Clinical assessments and treatment plans, Risk assessments and safeguarding documentation, Staff records (e.g., training, appraisals)Financial and operational data, It applies to all staff involved in the creation and management of records, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Leads, Pharmacists (in collaboration with Signature RX)Administrative Staff, Governance and Compliance Teams, It covers: Creation and maintenance of records, Storage and security of records, Access to and sharing of records, Retention and disposal of records, Monitoring and auditing of record-keeping practices

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all records are accurate, complete, and up to date. Maintaining secure and confidential records in line with data protection regulations. Providing staff with guidance and training on record-keeping standards. Ensuring that patients and staff have appropriate access to their records. Retaining and disposing of records in line with legal and professional standards. Promoting a culture of accountability and professionalism in record keeping.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines:UK General Data Protection Regulation (UK GDPR)Data Protection Act 2018Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Freedom of Information Act 2000Human Rights Act 1998Care Quality Commission (CQC) Regulations, National Institute for Health and Care Excellence (NICE) Guidelines, Royal College of Nursing (RCN) Guidelines on Record Keeping, General Medical Council (GMC) Guidance on Clinical Documentation, Nursing and Midwifery Council (NMC) Code of Conduct, British National Formulary (BNF)

5. Procedure

5.1 Principles of Record Keeping

BrightPath Neuro follows key principles of record keeping to ensure the highest standards of clinical documentation. Records must be accurate, factually correct, and free from errors; complete, containing all relevant information; and legible, clear, and easily understood. They must be updated promptly following any clinical activity and handled with security to protect against unauthorised access. Confidentiality is paramount, and all entries must be traceable, meaning they are signed and dated to ensure accountability.

5.2 Types of Records

Clinical Records: Patient medical records, Clinical assessments and reports, Treatment and medication plans, Risk assessments and care plans, Test results and diagnostic reports, Prescribing Records: Controlled drug prescriptions, Medication titration plans, Adverse drug reaction reports, Administrative Records: Staff training records, Financial records, Incident reports, Appointment schedules, Safeguarding and Risk Management: Safeguarding referrals and investigations, Incident reports, Risk assessments and safety plans

5.3 Creating and Maintaining Records

Initial Record Creation: Patient records must be created at the first point of contact. All patient records must include: Full name and date of birth, NHS or patient identification number, Address and contact details, Referring clinician (if applicable)Consent documentation, Clinical Documentation: Clinical records must include: Date and time of entry, Full details of clinical assessment, Symptoms, observations, and test results, Diagnosis (if applicable)Treatment plans, medication prescribed, and dosage, Patient consent and understanding of treatment, Follow-up and next steps, Prescribing and Medication Records: Prescriptions for controlled drugs must include: Drug name, strength, and formulation, Total quantity (in figures and words)Dosage instructions, Prescribing clinician’s full name, registration number, and signature. Incident Reporting and Risk Management: All incidents and safeguarding concerns must be recorded using the BrightPath Neuro Incident Reporting Form. Incident reports must be submitted within 24 hours of the event. Risk assessments must be reviewed and updated following any significant incident.

5.4 Access and Sharing of Records

Patient Access: Patients have the right to access their medical records under the UK GDPR. Requests for access must be processed within 30 days. A copy of the records must be provided in a secure format. Third-Party Access: Information may only be shared with third parties when: There is valid patient consent. Disclosure is required by law. Disclosure is necessary to prevent harm to the patient or others. Requests for information from other healthcare providers must be documented.

5.5 Storage and Security of Records

Electronic Records: Electronic records must be stored on secure, encrypted systems. Access to electronic records must be password-protected. Audit logs must be maintained to monitor access to records. Paper-Based Records: Paper records must be stored in locked filing cabinets. Access to paper records must be restricted to authorised staff only. Paper records must be transported securely using sealed containers.

5.6 Retention and Disposal of Records

Retention: Patient records must be retained for a minimum of 8 years following the end of care. Records for children must be retained until the patient reaches the age of 25.Financial and operational records must be retained for 6 years. Disposal: Electronic records must be securely deleted when no longer required. Paper records must be shredded or destroyed using confidential waste disposal. A record of all data disposals must be maintained for audit purposes.

5.7 Incident Reporting and Investigation

Data Loss or Breach: Any loss of data or breach of confidentiality must be reported to the Data Protection Officer (DPO) within 24 hours. Serious breaches must be reported to the Information Commissioner’s Office (ICO) within 72 hours. Investigation: A full investigation must be completed within 5 working days. Findings must be documented, and corrective actions must be implemented.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of record-keeping practices. The Clinical Lead will monitor documentation accuracy and completeness. Non-compliance will be addressed through additional training and supervision.

7. Training and Awareness

All staff must complete annual training on: Clinical documentation standards, Confidentiality and data security, Record retention and disposal requirements

8. Responsibilities

Clinical Lead, Oversee record-keeping compliance. Governance Lead

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Physical Health Monitoring Policy

1. Purpose

This policy sets out the procedures and standards for the monitoring and management of physical health at BrightPath Neuro for patients receiving ADHD treatment or other neurodevelopmental care. Physical health monitoring is essential to ensure that any treatment provided, including medication, is safe and effective. Certain medications, particularly those used to treat ADHD (such as stimulants), can have an impact on cardiovascular health, growth, and other physical health parameters. Regular physical health checks help to minimise risks, identify adverse effects early, and optimise treatment outcomes. The purpose of this policy is to: Ensure that patients undergoing treatment for ADHD or other neurodevelopmental conditions receive regular physical health monitoring. Identify and respond to adverse effects and health risks associated with medication. Ensure that physical health monitoring is conducted in line with national guidelines and professional standards. Promote a patient-centred approach to physical health monitoring. Ensure that findings from physical health monitoring are documented and used to inform care plans.

2. Scope

This policy applies to all patients receiving care and treatment at BrightPath Neuro, including but not limited to: Patients undergoing ADHD assessment and treatment, Patients receiving medication for neurodevelopmental conditions, Patients with co-morbid physical health issues requiring monitoring, Children and young people, including those under the age of 18It applies to all staff involved in patient care, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists, Clinical Leads, Nurses and Healthcare Assistants, It covers: Pre-treatment physical health assessments, Ongoing physical health monitoring, Documentation of physical health checks, Responding to physical health concerns and adverse effects, Communication with other healthcare providers

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all patients receive appropriate physical health monitoring. Monitoring the physical health of patients receiving medication for ADHD or other neurodevelopmental conditions in line with national guidelines. Identifying and managing adverse effects related to medication and treatment. Providing staff with appropriate training and resources to carry out physical health monitoring. Promoting a patient-centred and evidence-based approach to physical health care. Ensuring that all physical health monitoring activities are accurately documented and monitored.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines NG87 – Diagnosis and management of ADHD, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Capacity Act 2005Human Rights Act 1998Care Quality Commission (CQC) Regulations, British National Formulary (BNF)Royal Pharmaceutical Society Guidelines, Children Act 1989 and 2004

5. Procedure

5.1 Pre-Treatment Physical Health Assessment

Before starting medication or any treatment that may affect physical health, a comprehensive baseline health assessment must be conducted. This assessment should include: Cardiovascular Health: Blood pressure and heart rate, History of cardiac problems (e.g., arrhythmias, congenital heart disease)Family history of sudden cardiac death or early cardiac disease, Height and Weight: Measurement of height and weight, Calculation of Body Mass Index (BMI)Plotting on appropriate growth charts (for children and adolescents)Mental Health and Neurological History: History of seizures, History of tics or other neurological conditions, Substance Use: Screening for alcohol, tobacco, or recreational drug use, Sleep: Assessment of sleep patterns and sleep hygiene, Medication and Allergy History: Current medications and supplements, History of medication allergies or adverse drug reactions, Physical Examination: General physical examination including: Respiratory rate, Cardiovascular examination, Neurological assessment (if indicated)

5.2 Ongoing Physical Health Monitoring

Frequency of Monitoring: After initiating ADHD medication, physical health monitoring must occur: 2 weeks after starting treatment, Every 3 months during the first year of treatment, Every 6 months thereafter, unless otherwise indicated, For patients on long-term medication, a comprehensive review should be conducted annually. Monitoring Parameters: Blood Pressure and Heart Rate: Must be measured and recorded at each follow-up appointment. Results must be compared to baseline values and previous readings. Height and Weight: Must be measured and plotted on growth charts for patients under 18 years old. Significant changes (≥1 centile line drop or gain) should be reviewed. Cardiac Monitoring: For patients with known cardiac conditions or concerning family history, an ECG must be conducted before starting medication. For ongoing treatment, an ECG must be repeated if: There is a significant increase in heart rate or blood pressure. The patient reports symptoms such as palpitations or chest pain. Sleep and Appetite: Patients must be assessed for changes in sleep and appetite. Medication adjustments may be required if significant sleep disruption or appetite loss occurs. Mental Health and Behaviour: Changes in mood, anxiety, and behaviour must be monitored. Patients reporting suicidal ideation, self-harm, or aggression must be referred for an urgent mental health review.

5.3 Responding to Abnormal Findings

Elevated Blood Pressure or Heart Rate: If blood pressure or heart rate exceeds the 95th percentile for age and gender: Repeat the measurement after 5 minutes. If elevated, consider reducing the medication dose or switching medication. If severe hypertension is present, refer to a cardiologist. Cardiac Symptoms: Symptoms such as chest pain, palpitations, or syncope should result in an immediate medical review. Medication should be suspended pending further investigation. Growth Retardation or Weight Loss: If height or weight drops more than one centile line: Review medication dosage and schedule. Consider drug holidays or alternative medications. Sleep Disruption: Persistent sleep issues should prompt a medication review. Consider non-stimulant medications or behavioural sleep interventions. Neuropsychiatric Symptoms: If the patient develops tics, aggression, or psychosis: Suspend the medication. Refer for psychiatric assessment.

5.4 Documentation

Recording: All physical health checks must be documented in the patient’s electronic health record. The record must include: Date and time of measurement, Result of each parameter (e.g., blood pressure, heart rate)Changes to treatment plan (if applicable)Any reported side effects or adverse reactions, Communication with GP: Significant findings must be shared with the patient’s GP within 48 hours. Changes to medication or treatment plan should be communicated promptly.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of physical health monitoring records. The Governance Lead will monitor compliance with NICE guidelines and internal protocols. Findings from audits will be reported to the Clinical Governance Committee.

7. Training and Awareness

All staff involved in physical health monitoring must complete annual training on: Cardiovascular monitoring, Growth and development standards, Identifying and managing medication side effects

8. Responsibilities

Clinical Lead, Oversee physical health monitoring standards. Governance Lead, Monitor compliance and report findings. Prescribers, Ensure regular monitoring and documentation.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Titration and Medication Adjustment Policy

1. Purpose

This policy sets out the procedures and guidelines for the titration and adjustment of medication at BrightPath Neuro for patients diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and other neurodevelopmental or mental health conditions. Titration refers to the process of gradually adjusting medication dosage to achieve the optimal balance between therapeutic benefit and minimisation of side effects. Effective titration and medication adjustments are essential for ensuring that patients receive safe, effective, and personalised care.The purpose of this policy is to:Ensure that medication titration and adjustment are conducted in line with clinical guidelines and best practices.Minimise the risk of adverse effects and medication intolerance.Optimise the clinical effectiveness of prescribed medications.Ensure that titration and medication adjustments are accurately documented.Provide a clear framework for monitoring patient response and adjusting treatment plans.

2. Scope

This policy applies to all patients receiving titration and medication adjustments at BrightPath Neuro, including but not limited to: Patients diagnosed with ADHD, Patients undergoing treatment for neurodevelopmental conditions, Patients receiving combination medication therapy, Children, adolescents, and adults under care at BrightPath Neuro, It applies to all staff involved in prescribing and monitoring medication, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists, Clinical Leads, Nurses and Healthcare Assistants, It covers: Initial medication titration, Dose adjustments, Monitoring of medication effectiveness and side effects, Management of adverse reactions, Communication with patients and caregivers

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that medication titration and adjustment are conducted safely and in line with professional standards. Minimising the risk of adverse effects through careful dose adjustments. Providing personalised titration plans based on patient response and tolerance. Monitoring the clinical effectiveness of medication and modifying treatment plans accordingly. Ensuring that patients and their caregivers understand the titration and adjustment process. Maintaining accurate records of medication titration and adjustments.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines NG87 – Diagnosis and management of ADHD, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Mental Capacity Act 2005British National Formulary (BNF)Royal Pharmaceutical Society Guidelines, Human Rights Act 1998Children Act 1989 and 2004

5.1 Principles of Titration and Medication Adjustment

At BrightPath Neuro, medication titration and dose adjustment are guided by key principles to ensure safe and effective treatment. Care is Individualised, with adjustments tailored to each patient’s clinical needs, response, and tolerance. A slow and steady approach is adopted, gradually increasing doses to minimise side effects and enhance tolerability. All practices are rooted in evidence-based guidance, following NICE and GMC recommendations. Emphasising patient-centred care, feedback from the individual informs decisions throughout the titration process. Monitoring and safety are prioritised, with regular assessments of both physical and mental health. Finally, all adjustments are carefully documented in the patient’s clinical records to maintain transparency and continuity of care.

5.2 Initial Titration of ADHD Medication

Pre-Titration Baseline Assessment: Before starting titration, a comprehensive baseline assessment must be conducted, including: Blood pressure and heart rate, Height and weight (if applicable)Cardiovascular history and ECG (if indicated)Mental health assessment, Substance use history, Current medication and allergy history, Starting Dose: The starting dose should be based on: Patient’s age and weight, Medical history, Current medication regimen, Starting doses should align with British National Formulary (BNF) and NICE guidelines. Patient Education: The patient (or caregiver) must be informed about: Purpose of the medication, Expected therapeutic benefits, Potential side effects, Signs of adverse reactions, Need for regular monitoring, Consent must be documented before starting medication.

5.3 Titration Schedule

General Titration Principles: Titration should follow a structured schedule, including: Initial review after 2 weeks, Second review after 4 weeks, Ongoing monitoring every 3 months for the first year, Dose increases should be small and gradual (in line with NICE guidelines).The minimum effective dose should be used to avoid side effects. Stimulant Medications (e.g., Methylphenidate):Increase dose by increments of 2.5 mg to 5 mg every 7 to 14 days until symptoms improve or side effects develop. Maximum dose should not exceed 60 mg/day for adults or 54 mg/day for children. Non-Stimulant Medications (e.g., Atomoxetine):Start at the recommended low dose based on weight. Increase every 2 to 4 weeks if tolerated and needed. Maximum dose should not exceed 100 mg/day.

5.4 Dose Adjustments

Criteria for Dose Adjustments: Dose adjustments should be made if: The patient experiences insufficient symptom improvement after 4 weeks. The patient develops side effects (e.g., increased heart rate, irritability, insomnia).The patient reports poor medication tolerance. Reducing the Dose: If side effects are significant, the dose should be reduced or the medication should be switched. Consider lowering the dose by 2.5 mg to 5 mg at each reduction step. Switching Medication: If two or more dose adjustments fail to achieve symptom relief, the medication should be reviewed. Consider switching to an alternative medication (e.g., from stimulant to non-stimulant).Combining Medications: Combination therapy (e.g., stimulant and non-stimulant) may be considered in resistant cases. All combination therapy must be approved by the Clinical Lead.

5.5 Monitoring During Titration

Blood Pressure and Heart Rate: Measure at each titration visit. Monitor for increased heart rate or hypertension. Weight and Appetite: Monitor for weight loss or growth suppression in children. Review nutritional intake and sleep patterns. Sleep and Behaviour: Assess for sleep disturbances, mood changes, or irritability. Adjust medication schedule or switch formulations if needed. Mental Health: Monitor for signs of depression, aggression, or suicidal ideation. Immediate review is required for significant mood or behavioural changes.5.6 Responding to Adverse Effects, Cardiac Symptoms: If chest pain, palpitations, or syncope occurs, stop medication immediately. Refer to a cardiologist if indicated. Weight Loss: If weight loss exceeds 5% of baseline body weight, review medication schedule. Consider drug holidays or alternative medications. Psychiatric Symptoms: If psychosis, mania, or aggression develops, stop medication and refer for psychiatric review.

5.6 Responding to Adverse Effects

Cardiac Symptoms: If chest pain, palpitations, or syncope occurs, stop medication immediately. Refer to a cardiologist if indicated. Weight Loss: If weight loss exceeds 5% of baseline body weight, review medication schedule. Consider drug holidays or alternative medications. Psychiatric Symptoms: If psychosis, mania, or aggression develops, stop medication and refer for psychiatric review.

5.7 Documentation

All titration and adjustments must be recorded in the patient’s clinical record: Date and time of titration, New dose and rationale, Patient’s response, Side effects and adverse reactions

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of titration and adjustment records. The Governance Lead will monitor compliance with titration protocols.

7. Training and Awareness

All staff involved in prescribing must complete annual training on titration and dose adjustment.

8. Responsibilities

Clinical Lead, Oversee titration and adjustment compliance. Prescribers, Ensure accurate titration and dose adjustments.

9. Review

This policy will be reviewed annually.

If you have a safeguarding concern, please contact us immediately. Our team takes safeguarding very seriously and follows strict protocols to ensure the safety and well-being of all clients. You can also report your concern directly by filling out our safeguarding form and reading our full Safeguarding Policy Here

 👉 Submit a Safeguarding concern,

Safeguarding and Vulnerability Policy

1. Introduction

Brightpath Neuro is committed to safeguarding and promoting the welfare of children, young people, and vulnerable adults. We have a duty of care to protect individuals from abuse, neglect, and exploitation. This policy outlines our approach to safeguarding, including the roles and responsibilities of staff and the procedures to follow in the event of a safeguarding concern.

2. Purpose

The purpose of this policy is to: Ensure a safe and secure environment for all service users. Promote the well-being of children, young people, and vulnerable adults. Ensure that staff understand their safeguarding responsibilities. Provide clear procedures for reporting and responding to safeguarding concerns.

3. Scope

This policy applies to: All staff, contractors, and volunteers working for Brightpath Neuro. All individuals receiving services from Brightpath Neuro, including children, young people, and vulnerable adults. Any external partners or agencies working with Brightpath Neuro.

4. Legal Framework

This policy is based on the following legislation and guidance: Children Act 1989 and 2004 Care Act 2014 Working Together to Safeguard Children (2018) Keeping Children Safe in Education (2023) Protection of Freedoms Act 2012 Data Protection Act 2018 and UK GDPR Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safeguarding Vulnerable Groups Act 2006

5. Definitions

5.1 Safeguarding

Safeguarding refers to the actions taken to protect the health, well-being, and human rights of individuals, particularly children and vulnerable adults, to prevent abuse, neglect, and exploitation.

5.2 Vulnerable Adult

A person aged 18 or over who: Has care and support needs. Is unable to protect themselves from harm or exploitation due to their care and support needs.

5.3 Abuse

Abuse is any action or inaction that causes harm, distress, or exploitation. Types of abuse include: Physical abuse – Assault, hitting, slapping, pushing, or misuse of medication. Sexual abuse – Non-consensual sexual activity or inappropriate touching. Emotional abuse – Verbal attacks, humiliation, or threats. Neglect – Failure to meet basic needs such as food, clothing, and healthcare. Financial abuse – Theft, fraud, or coercion in relation to money or property. Discriminatory abuse – Harassment or ill-treatment due to race, gender, age, or disability. Institutional abuse – Poor care practices within a service setting. Modern slavery – Forced labour, human trafficking, and exploitation.

6. Safeguarding Principles

Brightpath Neuro follows the six key safeguarding principles established in the Care Act 2014: Empowerment – Supporting individuals to make their own decisions. Prevention – Taking action before harm occurs. Proportionality – Responding appropriately to the level of risk. Protection – Providing support to those in greatest need. Partnership – Working with other agencies to safeguard effectively. Accountability – Ensuring transparency and clear decision-making.

7. Roles and Responsibilities

7.1 Safeguarding Lead

The Designated Safeguarding Lead (DSL) is responsible for: Overseeing safeguarding procedures. Acting as the primary contact for safeguarding concerns. Ensuring all staff receive safeguarding training. Liaising with external agencies, including social services and the police.

7.2 Staff and Volunteers

All staff and volunteers have a responsibility to: Be aware of the signs of abuse and neglect. Report safeguarding concerns to the DSL immediately. Follow safeguarding procedures outlined in this policy. Maintain confidentiality and professionalism when handling safeguarding issues.

7.3 Management

Senior management is responsible for: Ensuring that safeguarding policies and procedures are implemented. Providing resources for staff training and development. Monitoring safeguarding performance and compliance.

8. Safeguarding Procedures

8.1 Identifying a Safeguarding Concern

All staff should be aware of the following signs that may indicate abuse or neglect: Unexplained injuries or bruising. Sudden changes in behaviour or mood. Poor hygiene or malnutrition. Fearfulness, withdrawal, or reluctance to speak. Financial discrepancies or missing belongings.

8.2 Reporting a Concern

Any safeguarding concern must be reported immediately to the DSL. If the DSL is unavailable, the report should be escalated to senior management. Staff must record details of the concern accurately, including dates, times, and any actions taken. Reports should be made within 24 hours of the concern being identified.

8.3 Responding to a Concern

The DSL will assess the severity of the concern and take appropriate action. This may include: Contacting social services. Involving the police if a crime has been committed. Offering immediate support to the affected individual. The individual’s consent will be sought before sharing information unless there is a significant risk of harm.

8.4 Confidentiality and Information Sharing

Information will only be shared on a need-to-know basis. Safeguarding information will be stored securely in line with data protection laws. Staff must not disclose safeguarding information to unauthorised individuals.

8.5 Escalation Process

If a safeguarding concern is not resolved satisfactorily, staff and clients can escalate the issue to: Local Safeguarding Adults Board Local Safeguarding Children Partnership Care Quality Commission (CQC) Local Authority Safeguarding Team

9. Training and Development

All staff must receive safeguarding training at least once per year. New staff must complete safeguarding training as part of their induction. The DSL must complete enhanced safeguarding training and regular updates.

10. Safer Recruitment

Brightpath Neuro is committed to recruiting staff safely: All staff undergo Enhanced DBS (Disclosure and Barring Service) checks. References are checked prior to employment. Staff are assessed for suitability to work with vulnerable groups.

11. Allegations Against Staff

Any allegation against a staff member must be reported immediately to the DSL. The staff member may be suspended while an investigation takes place. Investigations will be carried out in line with local safeguarding procedures.

12. Whistleblowing

Brightpath Neuro encourages staff to report any safeguarding concerns without fear of retaliation. Whistleblowers are protected under the Public Interest Disclosure Act 1998. Concerns should be reported directly to the DSL or senior management.

13. Monitoring and Review

All safeguarding incidents and outcomes will be recorded and reviewed. This policy will be reviewed annually or after any major safeguarding incident. Feedback from staff and service users will be used to update this policy where appropriate.

Follow-Up and Monitoring Policy

1. Purpose

This policy sets out the procedures and guidelines for the follow-up and ongoing monitoring of patients at BrightPath Neuro. Follow-up and monitoring are critical to ensuring that patients receive safe, effective, and personalised care. Regular monitoring allows clinicians to track the progress of treatment, identify adverse effects, adjust medication or treatment plans, and address emerging health or psychological issues. A structured follow-up process also supports patient engagement and promotes better clinical outcomes. The purpose of this policy is to: Ensure that all patients receiving care at BrightPath Neuro are followed up regularly. Ensure that treatment plans are adjusted based on clinical response and patient feedback. Identify and respond to medication side effects and adverse events. Monitor patient progress and adherence to treatment. Provide a framework for recording and communicating follow-up outcomes. Ensure that follow-up and monitoring align with national guidelines and professional standards.

2. Scope

This policy applies to all patients receiving care and treatment at BrightPath Neuro, including but not limited to: Patients undergoing ADHD treatment (medication and behavioural interventions)Patients receiving medication titration, Patients with neurodevelopmental disorders or mental health conditions, Children, adolescents, and adults under the care of BrightPath Neuro, It applies to all staff involved in patient follow-up and monitoring, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists, Clinical Psychologists, Clinical Leads, Nurses and Healthcare Assistants, It covers: Initial follow-up after diagnosis or treatment initiation, Ongoing monitoring of medication and treatment outcomes, Identifying and responding to adverse events or treatment failure, Recording and communicating follow-up outcomes

3. Policy Statement

BrightPath Neuro is committed to: Providing regular follow-up and monitoring for all patients. Ensuring that treatment plans are adapted based on patient response and feedback. Monitoring for adverse drug reactions, medication tolerance, and treatment adherence. Responding promptly to any signs of treatment failure or emerging risks. Ensuring that all follow-up activities are accurately documented and communicated. Promoting a patient-centred and evidence-based approach to follow-up care.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines NG87 – Diagnosis and management of ADHD, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Mental Capacity Act 2005British National Formulary (BNF)Royal Pharmaceutical Society Guidelines, Human Rights Act 1998Children Act 1989 and 2004

5. Procedure

5.1 Principles of Follow-Up and Monitoring

BrightPath Neuro upholds key principles in its approach to follow-up and monitoring to ensure high-quality, patient-focused care. Continuity of care is maintained through consistent, structured follow-up tailored to each individual’s needs. Emphasising patient-centred care, follow-up plans are informed by patient feedback and clinical outcomes. Proactive monitoring enables early identification of adverse effects or treatment failures, while a focus on clinical effectiveness ensures that the best possible outcomes are achieved. Safety remains a priority, with ongoing monitoring of medication tolerance, side effects, and potential health risks. All follow-up activities are clearly documented and shared with the wider care team to promote transparency and accountability.

5.2 Initial Follow-Up After Diagnosis or Treatment Initiation

Timing of Initial Follow-Up: An initial follow-up must be scheduled: Within 2 weeks of starting medication or treatment, Within 7 days if the patient is at high risk (e.g., history of self-harm, cardiac issues)Initial Follow-Up Assessment: The initial follow-up must assess: Symptom improvement or deterioration, Presence of side effects or adverse drug reactions, Patient’s adherence to medication or treatment, Physical health parameters (e.g., blood pressure, heart rate, weight)Sleep patterns and appetite, Emotional and behavioural response to treatment, Documentation: The follow-up assessment must be recorded in the patient’s clinical record. Any adverse effects or medication adjustments must be documented.

5.3 Ongoing Follow-Up and Monitoring

At BrightPath Neuro, ongoing follow-up and monitoring are conducted regularly to ensure treatment remains safe and effective. During the initial titration period, follow-ups occur every four weeks, followed by three-monthly reviews during the first year of treatment. Thereafter, patients are reviewed every six months, unless clinical needs dictate otherwise. Those on stable long-term medication should have an annual review. Each follow-up assesses key monitoring parameters, including symptom improvement (e.g., reduction in ADHD or mental health symptoms), the presence of side effects such as insomnia, irritability, appetite loss, or tachycardia, and physical health markers like blood pressure, heart rate, and weight. Sleep patterns and appetite are monitored closely, alongside emotional and behavioural status, including mood, aggression, and emotional regulation. Medication adherence is confirmed at each review, and patient satisfaction—including feedback from caregivers—is gathered to inform the ongoing treatment plan.

5.4 Criteria for Adjusting Treatment

During Follow-Up Symptom Persistence: If symptoms persist after 4 weeks of treatment: Consider increasing the dose (if tolerated).Review for potential drug resistance or absorption issues. Adverse Effects: If the patient develops significant side effects (e.g., tachycardia, psychosis): Reduce or discontinue the medication. Consider alternative medications. Non-Adherence: If the patient is not adhering to medication: Explore barriers to adherence. Consider alternative treatment formulations (e.g., long-acting).Physical Health Decline: If blood pressure or weight changes significantly: Reduce medication dose. Consider a drug holiday or alternative treatment.

5.5 Urgent or Emergency Follow-Up

Cardiac Symptoms:If the patient reports chest pain, syncope, or palpitations: Stop medication immediately.Arrange an urgent cardiac review.Psychiatric Symptoms:If the patient develops aggression, psychosis, or suicidal ideation: Stop medication.Arrange an urgent psychiatric review.Severe Weight Loss:If the patient loses more than 5% of body weight: Adjust medication dose.Refer to a dietitian if necessary.

5.6 Communication of Follow-Up Outcomes

Internal Communication: All follow-up findings must be documented in the patient’s clinical record. Medication adjustments must be communicated to the prescribing team. External Communication: Significant changes in medication or treatment plans must be shared with the patient’s GP within 48 hours. Multidisciplinary team (MDT) meetings should be arranged for complex cases.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of follow-up and monitoring records. The Governance Lead will review audit findings and implement corrective actions where needed. Non-compliance with follow-up standards will result in additional training or disciplinary action.

7. Training and Awareness

All staff involved in follow-up and monitoring must complete annual training on: Clinical assessment techniques, Medication adjustment protocols, Adverse event reporting and management

8. Responsibilities

Clinical Lead, Oversee follow-up and monitoring compliance. Governance Lead, Monitor follow-up and documentation standards. Prescribing Clinicians, Ensure regular and accurate follow-up of patients.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Annual Review Policy

1. Purpose

This policy sets out the procedures and guidelines for conducting annual reviews for all patients under the care of BrightPath Neuro. Annual reviews provide an opportunity to evaluate the patient’s overall clinical progress, treatment effectiveness, and physical and mental health. Regular reviews help to identify emerging health concerns, optimise medication and treatment plans, and ensure that care remains patient-centred and evidence-based. The purpose of this policy is to: Ensure that all patients receiving care at BrightPath Neuro undergo a comprehensive annual review. Ensure that annual reviews are conducted consistently and in line with national guidelines. Provide a structured framework for assessing treatment outcomes, side effects, and patient well-being. Identify the need for ongoing or alternative care. Provide a clear process for recording and communicating annual review outcomes.

2. Scope

This policy applies to all patients receiving care and treatment at BrightPath Neuro, including but not limited to: Patients diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)Patients receiving medication for neurodevelopmental or mental health conditions, Patients with complex care needs, Children, adolescents, and adults under long-term follow-up, It applies to all staff involved in patient care, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Clinical Leads, Nurses and Healthcare Assistants, It covers: Scheduling and conducting annual reviews, Physical health monitoring during the annual review, Mental health and emotional well-being assessment, Reviewing medication and treatment effectiveness, Adjusting treatment plans based on clinical findings, Documentation and communication of review outcomes

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all patients receive a comprehensive annual review. Monitoring physical and mental health outcomes consistently. Evaluating the effectiveness of current treatment plans and adjusting them where necessary. Identifying and addressing emerging risks or adverse effects. Promoting a patient-centred approach to annual reviews. Maintaining accurate and secure records of all review findings.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines NG87 – Diagnosis and management of ADHD, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Mental Capacity Act 2005British National Formulary (BNF)Royal Pharmaceutical Society Guidelines, Human Rights Act 1998Children Act 1989 and 2004

5. Procedure

5.1 Principles of Annual Review

BrightPath Neuro conducts annual reviews in line with key principles to ensure safe, effective, and patient-focused care. A patient-centred approach is central, with treatment decisions guided by the individual’s experiences and feedback. Each review involves a holistic assessment, considering both physical and mental health. To support continuity of care, the same clinician or clinical team will conduct the review wherever possible. Clinical effectiveness is prioritised, with treatment plans adjusted in accordance with evidence-based practice. Proactive risk management is employed to identify and address any new or emerging health concerns. All aspects of the annual review are clearly documented and communicated appropriately to ensure accountability and coordinated care.

5.2 Scheduling of Annual Reviews

Annual Review TimeLine: An annual review should be scheduled within 12 months of the last comprehensive assessment. For patients with complex needs or ongoing medication adjustments, an earlier review may be scheduled at the clinician’s discretion. Patients who have stopped treatment or medication should still be offered an annual review. Appointment Notification: Patients and caregivers must be notified of the scheduled annual review at least 4 weeks in advance. Appointment reminders should be sent 7 days before the scheduled date. Patients should be encouraged to prepare questions or concerns in advance of the review.

5.3 Components of the Annual Review

The annual review must include the following elements:

5.3.1 Physical Health Assessment

Cardiovascular Monitoring: Blood pressure and heart rate, ECG (if indicated or if the patient is on stimulant medication)Growth and Development: Height and weight (for children and adolescents)Body Mass Index (BMI)Growth chart review, General Physical Health: Appetite and nutrition, Sleep patterns, Sexual health (if appropriate)Medication Side Effects: Insomnia, irritability, mood changes, Cardiovascular effects, Gastrointestinal symptoms (e.g., nausea, appetite suppression)

5.3.2 Mental Health and Well-Being

Symptom Improvement: Improvement in ADHD or mental health symptoms, Functional changes (e.g., school, work, relationships)Emotional and Behavioural Health: Mood stability and anxiety levels, Aggression or self-harm behaviours, Social and emotional functioning, Psychiatric Symptoms: Depression or suicidal ideation, Psychotic symptoms, Substance misuse

5.3.3 Medication and Treatment Review

Medication Adherence: Confirmation of correct use of medication, Identification of barriers to adherence, Titration or Dose Adjustments: Review of medication dosage and effectiveness, Adjustment of dose based on clinical response and side effects, Alternative or Adjunctive Treatment: Consideration of non-pharmacological interventions, Referral to psychological or behavioural therapy if needed

5.3.4 Safeguarding and Risk Assessment

Safeguarding: Identification of safeguarding concerns (e.g., domestic abuse, neglect)Reporting to local safeguarding authorities if required, Risk Assessment: Risk of self-harm, suicide, or aggression, Risk to others or vulnerability to exploitation, Mental capacity to consent to treatment

5.4 Adjustment of Treatment Plans

Criteria for Changing Treatment: Lack of clinical response after adequate titration, Significant side effects or poor medication tolerance, New co-morbid conditions requiring additional treatment, Referral for Further Assessment: Complex cases should be referred to the Clinical Lead for further review. Multidisciplinary team (MDT) input may be required for treatment-resistant cases.

5.5 Documentation

Clinical Records: All findings from the annual review must be documented in the patient’s clinical record. The record should include: Date of review, Clinician’s name, Physical and mental health findings, Treatment plan changes, Patient’s feedback and consent, Outcome Communication: Any medication or treatment changes must be communicated to the patient’s GP within 48 hours. A summary of the review findings must be shared with the patient (if requested).

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of annual review records. The Clinical Lead will review compliance with follow-up and monitoring protocols. Findings from audits will be reviewed by the Clinical Governance Committee.

7. Training and Awareness

All staff involved in annual reviews must complete annual training on: Clinical assessment techniques, Psychiatric and physical health screening, Medication titration and dose adjustment protocols, Adverse event reporting and management

8. Responsibilities

Clinical Lead, Oversee compliance with annual review standards. Governance Lead, Monitor and audit annual review completion rates. Prescribing Clinicians, Ensure completion of annual reviews for all patients.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Your satisfaction is important to us. If you're not happy with any part of our service, please contact us directly. We will listen to your concerns and work with you to resolve any issues quickly and professionally. You can also fill out our complaints form and read our full Complaints Policy Here

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Complaints and Feedback Policy

1. Introduction

Brightpath Neuro is committed to providing high-quality neurodiversity and mental health services. We value all feedback, including complaints, as they help us improve our services and ensure that we meet the highest standards of care and professionalism. We aim to handle all complaints fairly, sensitively, and promptly, ensuring that any issues raised are addressed effectively and in line with regulatory and professional standards.

2. Scope

This policy applies to: Clients using Brightpath Neuro’s services. Parents or guardians of clients (where applicable). Staff members and third parties involved in the provision of our services.

3. Purpose

The purpose of this policy is to: Provide a clear process for making a complaint. Ensure that complaints are handled fairly, consistently, and promptly. Identify areas for improvement based on feedback received. Ensure that all complaints are treated with respect and confidentiality.

4. Definition of a Complaint

A complaint is defined as any expression of dissatisfaction with: The quality of service provided by Brightpath Neuro. The conduct or behavior of staff members. The content, accuracy, or outcome of an assessment, report, or service. Communication issues or delays in response.

5. How to Make a Complaint

We encourage you to raise any concerns at the earliest opportunity so that we can address them quickly and effectively. Complaints can be made in the following ways: By Email: [email protected] By Phone: [Insert Business Phone Number] In Writing: [Insert Business Address] Please include the following details when making a complaint: Your full name and contact details. The nature of the complaint (including relevant dates and locations). The names of any staff involved (if known). Any supporting documents or evidence (if applicable).

6. Acknowledgement of Complaints

We will acknowledge receipt of your complaint within 2 working days. We will provide the name of the person handling your complaint and an estimated timeframe for resolving the issue.

7. Complaint Investigation Process

Step 1 – Initial Review The complaint will be assigned to a senior member of the team for investigation. The investigator will review the details and speak to any staff involved. Step 2 – Investigation We aim to complete the investigation within 10 working days. If the investigation requires more time, you will be informed of the reason for the delay and the new estimated completion date. Step 3 – Outcome and Resolution A written response will be provided detailing: The findings of the investigation. Any corrective actions or changes implemented. Any further steps you may wish to take if you remain dissatisfied. If the complaint is upheld, appropriate remedial action will be taken to prevent recurrence.

8. Escalation Process

If you are not satisfied with the outcome of your complaint, you can request a review of the decision by the Director of Clinical Services. A request for escalation should be made within 5 working days of receiving the initial outcome. The review will be conducted within 10 working days, and a final decision will be communicated in writing. If you are still dissatisfied after the escalation process, you may contact the relevant regulatory body: Contact Information for Regulatory Bodies: Care Quality Commission (CQC): Website: www.cqc.org.uk Phone: 03000 616161 Information Commissioner’s Office (ICO): Website: www.ico.org.uk Phone: 0303 123 1113

9. Confidentiality and Data Protection

All complaints will be treated with strict confidentiality. Information will only be shared with those directly involved in the complaint’s resolution. All data related to complaints will be handled in accordance with our Privacy Policy and the UK General Data Protection Regulation (UK GDPR).

10. Monitoring and Review

All complaints are logged and monitored to identify patterns and areas for improvement. This policy is reviewed annually to ensure compliance with legal and regulatory standards and to reflect any changes in service delivery.

11. Responsibilities

Staff Responsibilities: All staff are responsible for cooperating with investigations and supporting the resolution of complaints. Management Responsibilities: Senior management is responsible for ensuring that complaints are handled in line with this policy and that any necessary changes are implemented.

12. Policy Review

This policy will be reviewed annually or earlier if required by regulatory changes or internal feedback.

Patient Rights and Responsibilities

1. Purpose

This policy outlines the rights and responsibilities of patients receiving care at BrightPath Neuro. BrightPath Neuro is committed to ensuring that all patients are treated with dignity, respect, and fairness. Recognising patient rights and encouraging patient responsibility are key to creating a safe and collaborative healthcare environment. This policy aims to empower patients to make informed decisions about their care while ensuring that they understand their role in maintaining a respectful and professional relationship with healthcare providers. The purpose of this policy is to: Ensure that patients are aware of their legal and ethical rights when receiving care. Encourage patients to take an active role in their treatment and care decisions. Define the responsibilities of patients in maintaining a safe and respectful care environment. Provide a framework for addressing violations of patient rights and responsibilities.

2. Scope

This policy applies to all patients receiving care at BrightPath Neuro, including but not limited to: Patients undergoing ADHD and neurodevelopmental assessments, Patients receiving medication or other treatments, Patients receiving therapy or support services, Children, adolescents, and adults under the care of BrightPath Neuro, It also applies to: Parents, guardians, and caregivers involved in the patient’s care, All staff involved in patient care, including: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Clinical Leads, Administrative and Governance Staff, It covers: Patient rights related to privacy, dignity, and informed consent, Responsibilities of patients in adhering to treatment plans and maintaining respectful behaviour, Staff obligations to protect and uphold patient rights

3. Policy Statement

BrightPath Neuro is committed to: Respecting and protecting the rights of all patients. Promoting shared decision-making between patients and healthcare professionals. Ensuring that patients have access to information about their care. Encouraging patients to participate actively in their treatment plans. Protecting patients from harm, discrimination, and unfair treatment. Providing clear guidelines for resolving conflicts related to patient rights and responsibilities.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Human Rights Act 1998Mental Capacity Act 2005Children Act 1989 and 2004Equality Act 2010Data Protection Act 2018 (UK GDPR)

5. Procedure

5.1 Patient Rights

All patients receiving care at BrightPath Neuro have the following rights:

5.1.1 Right to Access Care

Patients have the right to access timely and appropriate care based on clinical need. Patients must not be denied care based on: Age, Race or ethnicity, Gender or sexual orientation, Disability, Religion or belief, Marital or civil partnership status

5.1.2 Right to Privacy and Confidentiality

Patients have the right to expect that their personal and health information will remain confidential. Patient information will only be shared with third parties when: The patient provides informed consent, Disclosure is required by law, Disclosure is necessary to protect the patient or others from harm

5.1.3 Right to Dignity and Respect

Patients have the right to be treated with respect, courtesy, and compassion. Staff must respect the patient’s personal, cultural, and religious beliefs. Patients have the right to receive care in a safe, clean, and comfortable environment.

5.1.4 Right to Informed Consent

Patients have the right to receive clear and accurate information about their care, including: Diagnosis and treatment options, Risks and benefits of treatment, Possible side effects and complications, Alternative treatments, Patients have the right to refuse or withdraw consent at any time.

5.1.5 Right to Be Heard

Patients have the right to provide feedback, raise concerns, and make complaints without fear of retaliation. Patients have the right to have their concerns investigated and responded to promptly.

5.1.6 Right to Be Involved in Care Decisions

Patients have the right to participate in decisions about their care and treatment. Patients have the right to access their medical records upon request. Patients have the right to be involved in discussions about medication changes and treatment plans.

5.1.7 Right to a Second Opinion

Patients have the right to seek a second opinion if they are not satisfied with their diagnosis or treatment. BrightPath Neuro will facilitate access to an independent clinician upon request.

5.1.8 Right to Safeguarding and Protection from Harm

Patients have the right to be protected from: Abuse (physical, emotional, sexual, financial)Neglect, Exploitation, BrightPath Neuro has a duty to report safeguarding concerns to the appropriate authorities.

5.2 Patient Responsibilities

All patients receiving care at BrightPath Neuro are expected to adhere to the following responsibilities:

5.2.1 Provide Accurate Information

Patients must provide accurate and complete information about their health, including: Medical historyCurrent medicationsAllergies and sensitivities

5.2.2 Follow Treatment Plans

Patients are responsible for following the agreed treatment plan. If the patient chooses not to follow the treatment plan, they must discuss this with their healthcare provider.

5.2.3 Respect Staff and Other Patients

Patients must treat staff and other patients with respect and courtesy. Abusive, threatening, or violent behaviour will not be tolerated. Patients must not engage in discrimination or harassment.

5.2.4 Attend Appointments

Patients must attend scheduled appointments or cancel in advance if they are unable to attend. Repeated failure to attend appointments without notice may result in review of continued care.

5.2.5 Medication Adherence

Patients must take medications as prescribed. If the patient experiences side effects or difficulties with medication, they must inform their healthcare provider.

5.2.6 Protect Confidentiality

Patients must not disclose personal information about other patients. Patients should respect the privacy of staff and other patients.

5.2.7 Provide Feedback

Patients are encouraged to provide feedback on their care experience. Patients must report concerns or dissatisfaction in a respectful manner.

5.3 Violations of Patient Responsibilities

Failure to Follow Treatment: If a patient consistently refuses or disregards medical advice, BrightPath Neuro may review their care plan. The patient may be referred to another provider if appropriate. Abusive Behaviour: Patients who engage in threatening, abusive, or violent behaviour may be asked to leave the facility.In cases of physical aggression, police involvement may be required. Confidentiality Breach: Patients who breach confidentiality may face termination of services (if appropriate).BrightPath Neuro will report unlawful breaches of confidentiality to the appropriate authorities.

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of patient complaints related to rights and responsibilities. The Clinical Lead will monitor compliance with patient consent and decision-making processes. Findings will be presented to the Clinical Governance Committee for action and review.

7. Training and Awareness

All staff must complete annual training on: Patient rights and responsibilities, Shared decision-making, Informed consent

8. Responsibilities

Clinical Lead: Oversee compliance with patient rights and responsibilities. Governance Lead: Monitor adherence to patient rights and responsibilities.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Emergency Care and Crisis Management Policy

1. Purpose

This policy sets out the procedures and guidelines for managing medical and mental health emergencies and crisis situations at BrightPath Neuro. BrightPath Neuro is not a crisis service and does not provide emergency medical or psychiatric care. However, BrightPath Neuro is committed to ensuring that staff are trained to recognise signs of crisis and respond appropriately by facilitating access to emergency services or signposting to appropriate crisis support services. The purpose of this policy is to: Clarify BrightPath Neuro's role and limitations in managing emergencies and crises. Ensure that patients in crisis are directed to appropriate emergency and crisis care services. Provide guidance to staff on how to respond to medical or psychiatric emergencies. Ensure that staff act promptly and professionally when a crisis occurs. Protect the safety and well-being of patients and staff during emergency situations.

2. Scope

This policy applies to: All patients receiving care at BrightPath Neuro. All staff involved in patient care and clinical support, including: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists, Clinical Psychologists, Clinical Leads, Administrative and Governance Staff, It covers: Medical and psychiatric emergencies, Responding to safeguarding concerns, Signposting to crisis services, Communication and documentation of emergency incidents

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that staff can identify and respond appropriately to emergency situations. Ensuring that patients are directed to the correct emergency or crisis care service when needed. Providing a calm and professional response during emergencies. Promoting patient safety and minimising risk during a crisis. Maintaining accurate records of emergency incidents. Ensuring compliance with relevant legal and regulatory requirements.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Health Act 1983 (amended 2007)Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Mental Capacity Act 2005Children Act 1989 and 2004Human Rights Act 1998

5. Procedure

5.1 BrightPath Neuro's Role in Emergency and Crisis Care

Non-Crisis Service: BrightPath Neuro does not provide 24/7 emergency or crisis care. BrightPath Neuro is a specialist service for neurodevelopmental and mental health assessments and treatment, not an acute or crisis care service. Limits of Care: BrightPath Neuro staff are not authorised to administer emergency medication (e.g., rapid tranquilisation).BrightPath Neuro does not provide inpatient care or physical health emergency treatment. Immediate Referral: If a patient presents with an emergency or crisis, BrightPath Neuro staff must: Stay calm and provide reassurance. Contact emergency services (999) if the patient is at immediate risk of harm. If there is no immediate danger, refer the patient to the appropriate crisis service.

5.2 Medical Emergencies

Medical emergencies may include: Chest pain or suspected heart attack, Severe breathing difficulties, Loss of consciousness, Seizure (if prolonged or atypical)Severe allergic reaction (anaphylaxis)Severe injury or bleeding, Response to Medical Emergency: Initial Response: If a patient shows signs of a medical emergency: Call 999 immediately. Provide reassurance to the patient. Keep the patient comfortable and safe until emergency services arrive.DO NOT administer medication unless specifically authorised to do so. If the Patient is Unconscious: Place the patient in the recovery position. Monitor breathing and pulse. Begin CPR if the patient is not breathing or has no pulse (if trained).Seizures: Ensure the patient is in a safe position and away from potential hazards. Do NOT attempt to restrain the patient. If the seizure lasts longer than 5 minutes or if another seizure follows, call 999.Anaphylaxis:If the patient shows signs of anaphylaxis (e.g., difficulty breathing, swelling, rash): Call 999 immediately. If the patient has an epinephrine auto-injector (e.g., EpiPen), assist them in using it.

5.3 Psychiatric Emergencies

Psychiatric emergencies may include: Acute psychosis, Severe agitation or aggression, Suicidal ideation with intent or plan, Self-harm requiring immediate medical attention, Severe emotional dysregulation, Response to Psychiatric Emergency: Initial Response: If the patient is at risk of immediate harm to themselves or others: Call 999 and request urgent mental health support. Ensure the patient is in a safe place. Provide reassurance and avoid confrontation. If the Patient is Aggressive or Agitated: Ensure personal safety first – do not attempt to restrain the patient. Use a calm and non-threatening tone. If the patient remains aggressive or threatening, remove other patients from the area and call 999.If the Patient Reports Suicidal Intent: Stay with the patient. Ask the patient if they have a plan to harm themselves. Contact the patient’s GP or local mental health crisis service. If the risk is immediate, call 999.

5.4 Safeguarding Emergencies

Immediate Threat to a Child or Vulnerable Adult: If a patient under 18 or a vulnerable adult is at immediate risk of harm: Call 999 immediately. Notify the Designated Safeguarding Lead as soon as possible. Reporting: Report safeguarding emergencies to the Local Safeguarding Board within 24 hours. Follow the BrightPath Neuro Safeguarding Policy.

5.5 Signposting to Crisis Services

BrightPath Neuro staff are required to ensure that patients are signposted to appropriate crisis support services when needed. This includes providing up-to-date contact information for key services such as NHS 111 (dial 111), the Samaritans (116 123), the Local NHS Crisis Team, Emergency Services (999), and the Mental Health Helpline, which may vary by location. All of these services are available 24 hours a day, 7 days a week, ensuring continuous access to urgent support in times of crisis.

5.6 Documentation of Emergencies

Incident Report: All emergency incidents must be documented using the BrightPath Neuro Incident Report Form within 24 hours. The report must include: Date and time of the incident, Description of the emergency, Actions taken, Outcome, Staff involved, Clinical Record: Details of the emergency should be added to the patient’s clinical record.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of emergency incident reports. The Governance Lead will monitor response times and compliance with emergency protocols. All serious incidents will be reviewed by the Clinical Governance Committee.

7. Training and Awareness

All staff must complete annual training on: Recognising signs of medical and psychiatric emergencies, Emergency response protocols, Managing aggressive behaviour and safeguarding emergencies

8. Responsibilities

Clinical Lead: Oversee compliance with emergency protocols. All Staff: Respond promptly and professionally to emergencies.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Equality and Accessibility Policy

1. Purpose

This policy sets out the procedures and guidelines for promoting equality, diversity, and accessibility at BrightPath Neuro. BrightPath Neuro is committed to providing a safe, inclusive, and respectful environment where all individuals are treated with dignity and have equal access to high-quality care and services. We recognise the importance of ensuring that no patient, staff member, or visitor experiences discrimination or barriers to care based on protected characteristics or other factors. The purpose of this policy is to: Ensure that all patients and staff are treated equally and fairly, regardless of protected characteristics. Promote an environment where diversity is valued and respected. Ensure that reasonable adjustments are made to support accessibility for patients and staff. Ensure compliance with legal and professional standards for equality and diversity. Create a framework for identifying and addressing discrimination and inequality.

2. Scope

This policy applies to: All staff working at BrightPath Neuro, including: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Clinical Leads, Administrative and Governance Staff, All patients receiving care at BrightPath Neuro, including: Children, adolescents, and adults, Patients with physical and mental health disabilities, Patients from all cultural, ethnic, religious, and social backgrounds, Visitors and contractors interacting with BrightPath Neuro, It covers: Promoting equality and diversity, Eliminating discrimination and harassment, Accessibility and reasonable adjustments, Raising and addressing complaints of discrimination

3. Policy Statement

BrightPath Neuro is committed to: Promoting equality of opportunity for all patients, staff, and visitors. Eliminating discrimination, harassment, and victimisation. Ensuring that services are accessible and inclusive. Providing reasonable adjustments to remove barriers to access and care. Encouraging a culture where diversity and difference are respected and valued. Taking prompt and appropriate action to address complaints of discrimination or inequality.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Equality Act 2010Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Human Rights Act 1998Care Quality Commission (CQC) Regulations, Mental Capacity Act 2005Children Act 1989 and 2004Nursing and Midwifery Council (NMC) Code of Conduct, General Medical Council (GMC) Professional Standards, National Institute for Health and Care Excellence (NICE) Guidelines, Public Sector Equality Duty, United Nations Convention on the Rights of Persons with Disabilities

5. Procedure

5.1 Protected Characteristics

Under the Equality Act 2010, BrightPath Neuro ensures that no individual is treated unfairly or disadvantaged based on the following protected characteristics: Age, Disability, Gender reassignment, Marriage and civil partnership, Pregnancy and maternity, Race (including ethnicity and nationality)Religion or belief, Sex, Sexual orientation

5.2 Promoting Equality and Diversity

BrightPath Neuro will: Respect Individual Differences: Treat all patients and staff with dignity and respect. Respect individual differences in cultural and religious beliefs. Provide Equal Access to Services: Ensure that services are available and accessible to all patients. Make reasonable adjustments to accommodate specific patient needs. Promote Inclusive Practice: Ensure that communication materials are clear and available in multiple formats (e.g., large print, audio).Ensure that facilities are accessible for patients with mobility challenges. Staff Awareness and Training: Provide staff with regular training on equality, diversity, and inclusion. Ensure that staff are aware of their responsibilities in promoting equality. Patient Choice: Respect patient preferences regarding care delivery. Provide options to ensure that patient choices are supported.

5.3 Eliminating Discrimination and Harassment

BrightPath Neuro will not tolerate discrimination, harassment, or victimisation against any patient, staff member, or visitor based on protected characteristics., Definition of Discrimination: Discrimination includes: Direct Discrimination – Treating someone less favorably due to a protected characteristic. Indirect Discrimination – Applying a policy or practice that disadvantages someone based on a protected characteristic. Associative Discrimination – Treating someone unfairly due to their association with someone with a protected characteristic. Perceptive Discrimination – Treating someone unfairly because they are perceived to have a protected characteristic. Definition of Harassment: Harassment includes: Unwanted conduct related to a protected characteristic that violates dignity. Intimidation, offensive comments, or threats. Bullying or abusive behaviour. Response to Discrimination and Harassment: All complaints of discrimination and harassment will be taken seriously. Staff involved in discrimination or harassment may face disciplinary action (up to and including termination).Patients involved in discrimination or harassment may have their access to services reviewed.

5.4 Accessibility and Reasonable Adjustments

BrightPath Neuro is committed to ensuring that services are accessible to all individuals, regardless of ability or need. Physical Accessibility: All BrightPath Neuro facilities must meet accessibility standards for individuals with disabilities. Accessible features must include: Step-free access, Disabled toilet facilities, Clear signage in accessible formats, Communication Accessibility: Information must be provided in accessible formats, including: Large print, Audio recordings, Braille (if requested)Alternative language translations, Patients with hearing impairments should have access to: British Sign Language (BSL) interpreters (if needed)Induction loops in public areas, Reasonable Adjustments: Reasonable adjustments should be made to meet individual patient needs, including: Flexible appointment times for patients with sensory sensitivities. Allowing a support person or advocate during appointments. Providing extra time for patients with communication difficulties. Adjusting medication schedules based on religious fasting requirements.

5.5 Complaints and Feedback

Raising a Concern: Patients or staff who believe they have experienced discrimination or harassment should report the issue to the Equality and Diversity Lead or the Clinical Lead. Complaints should be made through the BrightPath Neuro Complaints and Feedback Policy. Investigation: All complaints will be investigated within 14 days. The complainant will be kept informed of progress. Resolution: Findings will be communicated to the complainant. If discrimination is found to have occurred, corrective action will be taken. If the complainant is dissatisfied with the outcome, they may escalate the complaint to the Clinical Governance Committee or an external regulator (e.g., CQC).

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of equality and diversity practices. Findings and recommendations will be reviewed by the Clinical Governance Committee. Corrective actions will be implemented where gaps are identified.

7. Training and Awareness

All staff must complete annual training on: Equality and diversity awareness, Recognising and addressing discrimination, Implementing reasonable adjustments, Inclusive communication techniques

8. Responsibilities

Equality and Diversity Lead: Oversee equality and diversity practices at BrightPath Neuro. Clinical Lead: Ensure that services meet accessibility and equality standards. All Staff: Promote inclusive and respectful practice. Respond to discrimination and harassment appropriately.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Training and Competency Policy

1. Purpose

This policy sets out the procedures and guidelines for ensuring that all staff at BrightPath Neuro are appropriately trained, competent, and supported to deliver high-quality care. BrightPath Neuro recognises that staff competency is essential for maintaining high standards of clinical care, patient safety, and operational effectiveness. Ensuring that staff are adequately trained and supported to perform their roles enhances patient outcomes, minimises risk, and promotes professional growth. The purpose of this policy is to: Establish a framework for identifying training and competency requirements. Ensure that staff have access to appropriate training and development opportunities. Ensure that staff competency is assessed and monitored regularly. Ensure compliance with legal and professional requirements for staff training and competency. Promote a culture of continuous learning and improvement.

2. Scope

This policy applies to: All staff working at BrightPath Neuro, including: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Clinical Leads, Administrative and Governance Staff, Healthcare Assistants and Support Workers, All contracted and agency staff working under the direction of BrightPath Neuro. All new staff during their induction and onboarding period. It covers: Mandatory training requirements, Role-specific training and competency assessments, Ongoing professional development, Supervision and monitoring of staff competency, Performance management and corrective action for competency gaps

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all staff have the necessary skills, knowledge, and behaviours to perform their roles effectively. Providing high-quality training that aligns with national and professional standards. Encouraging staff to engage in continuous professional development (CPD).Monitoring staff competency regularly and addressing performance gaps promptly. Creating a learning environment where staff feel supported and confident in their roles. Ensuring that training and competency requirements are tailored to individual roles and responsibilities.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, British Psychological Society (BPS) Guidelines, Royal Pharmaceutical Society (RPS) Standards, National Institute for Health and Care Excellence (NICE) Guidelines, Data Protection Act 2018 (UK GDPR)Equality Act 2010

5. Procedure

5.1 Training and Competency Framework

BrightPath Neuro has implemented a comprehensive training and competency framework to ensure staff maintain the necessary skills and knowledge to deliver safe and effective care. This includes mandatory training in areas such as health and safety, safeguarding, equality and diversity, confidentiality, and data protection, with annual refreshers. Clinical skills training is provided as required, particularly when guidelines change, covering procedures like ADHD assessments and medication management. Staff also receive annual training in mental health and neurodevelopmental conditions, including ADHD, autism, and crisis management. Medication management training, encompassing prescribing, controlled drug policies, and titration, is refreshed annually. Training in communication and patient engagement, including managing difficult conversations and motivational interviewing, is delivered every two years, as is emergency and crisis response training, such as basic life support. Finally, IT and data security training, focused on clinical systems and confidentiality, is updated annually to ensure compliance with data protection standards.

5.2 Mandatory Training

Scope: All staff must complete the following mandatory training within 4 weeks of starting employment: Health and safety, Infection control, Safeguarding adults and children, Equality and diversity, Data protection and confidentiality, Fire safety, Record Keeping: All mandatory training must be recorded in the staff member's personnel file. The training completion rate will be monitored by the Governance Lead. Non-Completion of Mandatory Training: Staff who fail to complete mandatory training within the required timeframe will: Be removed from patient-facing duties until training is completed. Be subject to a formal performance review if non-compliance persists.

5.3 Clinical Skills Training

Role-Specific Competency: Clinical staff must demonstrate competency in role-specific skills, including: ADHD assessment and diagnosis, Medication prescribing and titration, Risk assessment and safeguarding procedures, Crisis management and de-escalation, Competency assessments must be completed within 3 months of starting employment. Assessment of Competency: Competency assessments must include: Direct observation, Knowledge tests, Patient feedback (where applicable)Competency sign-off will be conducted by a Clinical Lead or Senior Clinician. Competency Failures: Staff who fail competency assessments will: Receive additional training and support. Undergo a repeat assessment within 4 weeks. Be referred to the Clinical Lead for further review if competency is not achieved.

5.4 Ongoing Professional Development (CPD)

CPD Requirements: Clinical staff must complete a minimum of 20 hours of CPD per year. CPD may include: Attending training courses and workshops, Completing online learning modules, Peer supervision and reflective practice, Professional conferences, Staff must maintain a CPD portfolio. Funding and Support: BrightPath Neuro will provide financial and logistical support for staff CPD. Staff may request study leave for approved CPD activities.

5.5 Supervision and Performance Review

Clinical Supervision: Clinical staff must attend monthly clinical supervision sessions with a senior clinician. Supervision will include: Case reviews, Reflection on practice, Identifying learning needs, Providing feedback, Annual Performance Review: All staff must have an annual performance review, including: Review of competency and training completion, Identification of training and development needs, Feedback from colleagues and patients, Performance review outcomes will be documented and added to the staff member's personnel file.

5.6 Corrective Action for Competency Gaps

Identification of Gaps: Competency gaps may be identified through: Direct observation, Supervision and case reviews, Patient feedback, Incident reports, Remedial Action: Staff with identified competency gaps will: Receive additional training within 4 weeks. Be assigned a mentor for support and monitoring. Be subject to a performance improvement plan if competency is not achieved. Failure to Improve: Staff who fail to meet competency requirements after remedial action will: Be referred to the Clinical Lead. Be subject to disciplinary action (if appropriate).

6. Monitoring and Compliance

The Governance Lead will conduct quarterly audits of staff training and competency records. The Clinical Lead will review competency assessment outcomes. The Clinical Governance Committee will review training completion rates and competency issues quarterly.

7. Training and Awareness

All staff must complete annual training on: Equality and diversity, Safeguarding and crisis response, Professional conduct and communication

8. Responsibilities

Clinical Lead: Oversee clinical training and competency assessments. Governance Lead: Monitor training completion rates and compliance. All Staff: Complete all required training. Maintain competence in their role.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Controlled Drug (CD) Handling and Prescribing Policy

1. Purpose

This policy sets out the procedures and guidelines for the handling, prescribing, and management of Controlled Drugs (CD) at BrightPath Neuro. Although BrightPath Neuro does not store, administer, or dispose of controlled drugs, prescribing is conducted through Signature RX, BrightPath Neuro’s designated pharmacy partner. This policy ensures that prescribing and management of Controlled Drugs comply with legal and professional standards and that any issues are promptly reported and investigated. The purpose of this policy is to: Ensure that all Controlled Drugs (CDs) prescribed through BrightPath Neuro are managed in line with legal and professional requirements. Provide clear guidelines for prescribing and monitoring of CDs. Establish a framework for identifying and investigating prescribing or handling errors. Ensure the safe and effective use of CDs in patient care.

2. Scope

This policy applies to all staff involved in prescribing and managing Controlled Drugs, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists, Clinical Leads, It covers: Prescribing of Controlled Drugs, Monitoring and reviewing CD prescriptions, Reporting and investigating prescribing incidents, Record keeping and auditing

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all Controlled Drugs are prescribed safely and appropriately. Complying with legal and regulatory requirements for Controlled Drugs. Ensuring that all prescribing staff receive training and supervision in CD management. Investigating and responding promptly to any CD-related prescribing incidents. Working in partnership with Signature RX to ensure secure handling and delivery of Controlled Drugs.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Misuse of Drugs Act 1971Misuse of Drugs Regulations 2001Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Prescribing Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Royal Pharmaceutical Society Guidelines, Controlled Drugs (Supervision of Management and Use) Regulations 2013

5. Procedure

5.1 Prescribing of Controlled Drugs

Authorised Prescribers: Only authorised Medical Practitioners and Non-Medical Prescribers (NMPs) may prescribe Controlled Drugs. Prescribers must be registered with the General Medical Council (GMC) or Nursing and Midwifery Council (NMC).Prescribers must have completed training in CD prescribing. Prescribing Criteria: Controlled Drugs may be prescribed if: There is a clear clinical indication. Risks and benefits have been discussed with the patient. Alternative treatments have been considered. The prescriber has assessed the patient’s mental capacity to consent. Prescribing Procedure: All CD prescriptions must include: Patient’s full name, address, and date of birth, Drug name, form, strength, and total quantity (in words and figures)Dose, frequency, and route of administration, Prescriber’s full name, registration number, and signature, Prescriptions must be written clearly and without alterations. Electronic Prescribing: Prescribers must log into the Signature RX system using a secure login. A unique access code must be used to authorise CD prescriptions. E-prescribing of CDs must comply with Signature RX’s security protocols. Wet Signature Requirement: Under the Misuse of Drugs Act 1971, CDs in Schedules 2 and 3 require a wet signature. Wet signature prescriptions must be submitted to Signature RX within 24 hours of signing.

5.2 Monitoring and Review

Initial Monitoring: All patients prescribed CDs must be reviewed within 2 weeks of starting medication. Monitoring must include: Symptom improvement, Side effects or adverse reactions, Signs of dependence or misuse, Ongoing Monitoring: Patients receiving long-term CDs must be reviewed every 3 months. Monitoring should include: Blood pressure and heart rate (if indicated)Mental health and emotional well-being, Risk of dependence or tolerance, Medication Adjustments: Dose adjustments should be made gradually to minimise side effects. If tolerance or misuse is suspected, medication should be reduced or stopped. Alternative treatments should be considered if the CD is ineffective or poorly tolerated.

5.3 Record Keeping

Clinical Records: All CD prescriptions and reviews must be documented in the patient’s clinical record. Records should include: Date of prescription, Medication details and dose, Clinical rationale for prescribing, Patient consent, Side effects and monitoring outcomes, Audit Records: CD prescribing records must be retained for 7 years. Signature RX will maintain a controlled drug register.

5.4 Reporting and Investigation of Incidents

Definition of a CD Incident: A Controlled Drug incident includes: Prescribing errors (e.g., wrong dose, formulation, or frequency)Failure to obtain informed consent, Signs of dependence or misuse, Patient complaints about CD prescribing, Incident Reporting: All CD incidents must be reported within 24 hours using the BrightPath Neuro Incident Reporting Form. Reports must be submitted to the Clinical Lead and Governance Lead. Serious incidents must be reported to the Care Quality Commission (CQC) within 72 hours. Investigation Process: The Clinical Lead will conduct a full investigation within 5 working days. The investigation should include: A review of the patient’s clinical record, Staff interviews (if required)A review of Signature RX’s dispensing records, Findings will be documented in the patient’s clinical record. Outcome and Corrective Action: If a prescribing error is confirmed: The patient must be informed of the incident and corrective action taken. The prescriber may be required to undergo additional training. The Clinical Lead will monitor prescribing practices for 3 months. If a serious breach of CD regulations occurs, the prescriber may be subject to: Formal disciplinary action, Referral to the General Medical Council (GMC) or Nursing and Midwifery Council (NMC)Reporting to External Authorities: Serious incidents must be reported to the Controlled Drugs Accountable Officer and the Care Quality Commission (CQC).Incidents involving criminal activity must be reported to the police.

5.5 Staff Training and Competency

Mandatory Training: All staff involved in prescribing CDs must complete training on: Safe prescribing practices, CD legislation and regulations, Identifying and managing CD dependence, Incident reporting procedures, Competency Assessment: Prescribing staff must demonstrate competency through: Direct observation, Case reviews, Knowledge assessments

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of CD prescribing records. The Governance Lead will monitor CD prescribing patterns. On-compliance will be addressed through training and disciplinary action.

7. Training and Awareness

Staff must complete annual refresher training on CD prescribing and incident reporting.

8. Responsibilities

Clinical Lead: Oversee CD prescribing practices and compliance. Governance Lead: Investigate and report CD incidents. All Prescribers: Ensure accurate and safe prescribing of CDs.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Audit and Quality Assurance Policy

1. Purpose

This policy sets out the procedures and guidelines for conducting audits and quality assurance (QA) activities at BrightPath Neuro. Auditing and quality assurance are essential to ensuring that services provided at BrightPath Neuro meet legal, professional, and regulatory standards. Regular audits and quality reviews help to identify strengths, areas for improvement, and compliance issues, ensuring that care remains effective, safe, and patient-centred. The purpose of this policy is to: Ensure that care and services provided at BrightPath Neuro meet high standards of quality and safety. Establish a structured framework for conducting internal audits and quality reviews. Promote a culture of continuous improvement. Ensure that corrective actions are identified and implemented where gaps are identified. Ensure compliance with legal and professional requirements for clinical governance.

2. Scope

This policy applies to: All clinical and administrative activities at BrightPath Neuro. All staff involved in patient care and service delivery, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Clinical Leads, Healthcare Assistants and Support Workers, Administrative and Governance Staff, It covers: Clinical audits, Operational and process audits, Prescribing and medication audits, Patient safety and safeguarding audits, Complaints and incident review audits, Staff training and competency audits

3. Policy Statement

BrightPath Neuro is committed to: Maintaining high standards of clinical care and patient safety. Conducting regular audits to assess the quality and effectiveness of services. Acting on audit findings to address gaps and improve performance. Ensuring that staff participate actively in quality improvement activities. Meeting all regulatory and professional standards for quality assurance and clinical governance.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, Royal Pharmaceutical Society (RPS) Standards, National Institute for Health and Care Excellence (NICE) Guidelines, Data Protection Act 2018 (UK GDPR)Human Rights Act 1998Equality Act 2010

5. Procedure

5.1 Types of Audits and Quality Assurance Activities

BrightPath Neuro undertakes a range of audits and quality assurance activities to maintain high standards of care and service delivery. Clinical audits are conducted quarterly to assess patient care, diagnosis, treatment, and outcomes. Prescribing and medication audits, also carried out quarterly, review prescribing practices, medication titration, and the handling of controlled drugs. Operational audits take place bi-annually, focusing on administrative processes, patient communication, and appointment scheduling. Patient safety audits, conducted quarterly, review incidents, safeguarding concerns, and risk assessments. Training and competency audits are performed annually to ensure staff meet required standards. Additionally, patient feedback audits are completed quarterly to evaluate satisfaction, address complaints, and incorporate patient input into service improvements.

5.2 Clinical Audits

Purpose: Ensure that clinical care aligns with evidence-based guidelines (e.g., NICE).Identify variations in practice and care delivery. Improve clinical outcomes and patient experience. Scope: ADHD assessment and diagnosis processes, Medication prescribing and titration outcomes, Management of mental health and behavioural symptoms, Risk assessment and crisis management, Process: The Clinical Lead will establish an audit schedule. Clinical audits will involve: Review of patient records, Direct observation of care delivery, Staff interviews (if required)Audit findings will be presented to the Clinical Governance Committee. Outcomes: Identified gaps will be addressed through: Additional staff training, Process improvements, Policy updates

5.3 Prescribing and Medication Audits

Purpose: Ensure safe and effective prescribing practices. Ensure that Controlled Drugs (CDs) are prescribed and monitored appropriately. Scope: All prescriptions (including CDs)Electronic prescribing through Signature RX, Documentation of patient consent and side effects monitoring, Process: The Clinical Pharmacist will conduct quarterly audits. The audit will assess: Accuracy of prescriptions, Monitoring of side effects, Patient consent and education, Findings will be reported to the Clinical Lead. Outcomes: Identified prescribing errors will be corrected immediately. Prescribers involved in repeated errors will undergo additional training.

5.4 Operational and Process Audits

Purpose: Ensure that administrative processes support high-quality patient care. Identify and resolve scheduling, communication, and record-keeping issues. Scope: Appointment booking and patient correspondence, Electronic health record (EHR) management, Patient confidentiality and data protection, Process: The Governance Lead will conduct bi-annual operational audits. The audit will assess: Efficiency and accuracy of administrative processes, Compliance with data protection regulations, Patient complaints and feedback, Outcomes: Recommendations for improving efficiency and accuracy will be implemented.

5.5 Patient Safety and Safeguarding Audits

Purpose: Ensure that safeguarding protocols are followed. Identify and reduce patient safety risks. Scope: Incident reports and adverse event logs, Safeguarding referrals and follow-up actions, Risk assessment documentation, Process: The Safeguarding Lead will conduct quarterly audits. The audit will assess: Timeliness and effectiveness of safeguarding responses, Compliance with safeguarding reporting requirements, Outcomes: Corrective action plans will be implemented where safeguarding failures are identified.

5.6 Staff Training and Competency Audits

Purpose: Ensure that staff have the required skills and knowledge to provide safe care. Ensure that mandatory training is up to date. Scope: Completion of training records, Competency assessments, Supervision and appraisal records, Process: The Training Lead will conduct an annual audit. The audit will assess: Completion of training requirements, Staff feedback on training effectiveness, Outcomes: Staff who fail to meet training requirements will undergo additional training.

5.7 Reporting and Action Plans

Audit Reports: A formal report will be prepared for each audit. Reports will include: Summary of findings, Identified gaps or failures, Recommended corrective actions, Responsible lead and timeline for resolution, Action Plans: Action plans will be monitored by the Clinical Governance Committee. Progress will be reviewed at the next scheduled committee meeting. Escalation: Serious failures will be reported to the Care Quality Commission (CQC).Repeat failures will result in disciplinary action.

6. Monitoring and Compliance

The Governance Lead will maintain a record of all audits and quality reviews. The Clinical Governance Committee will oversee audit outcomes and action plans. Progress on corrective actions will be tracked monthly.

7. Training and Awareness

All staff must complete annual training on: Quality improvement, Incident reporting, Clinical governance

8. Responsibilities

Clinical Lead: Oversee clinical audit activities. Governance Lead: Monitor audit completion and compliance. All Staff: Participate in audits and quality reviews.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (for ASC)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for Autism Spectrum Condition (ASC) at BrightPath Neuro. BrightPath Neuro is committed to providing a structured, evidence-based approach to assessing and diagnosing ASC. Early and accurate identification of ASC allows for timely intervention, support, and improved patient outcomes. This policy ensures that the initial assessment and screening process is consistent, patient-centred, and compliant with national guidelines. The purpose of this policy is to: Establish a clear framework for the initial assessment and screening of ASC. Ensure that assessments are evidence-based and conducted by trained professionals. Promote a patient-centred approach to assessing ASC. Ensure that assessment outcomes are clearly communicated to patients and caregivers. Ensure that follow-up and post-assessment support are in place.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for ASC assessment. All staff involved in the ASC assessment process, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Leads, Healthcare Assistants and Support Workers, Administrative Staff, it covers: Initial referral and triage, Screening tools and assessment protocols, Diagnostic interviews and observations, Communication of findings, Post-assessment follow-up and support

3. Policy Statement

BrightPath Neuro is committed to: Providing an evidence-based, patient-centred approach to ASC assessment and diagnosis. Ensuring that all ASC assessments are conducted by appropriately trained clinicians. Offering a timely and accessible assessment process. Providing comprehensive feedback and support to patients and caregivers. Ensuring that assessments are conducted in line with national guidelines and best practices.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, National Institute for Health and Care Excellence (NICE) Guidelines NG11 – Autism spectrum disorder in under 19s: recognition, referral, and diagnosis, National Institute for Health and Care Excellence (NICE) Guidelines CG128 – Autism spectrum disorder in adults: diagnosis and management, General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, British Psychological Society (BPS) Guidelines, Royal College of Psychiatrists Guidance, Mental Capacity Act 2005Equality Act 2010

5. Procedure

5.1 Referral and Triage

Referral Sources: Patients may be referred for an ASC assessment from: General Practitioners (GP)School or educational psychologists, Child and Adolescent Mental Health Services (CAMHS)Adult mental health services, Social care providers, Self-referral (if aged 18+)Initial Referral Review: The Clinical Lead or designated staff member will review all referrals within 5 working days. Referrals should include: Reason for referral, Relevant medical and mental health history, Family and developmental history, Educational and social functioning information, Incomplete referrals will be returned with a request for additional information. Triage: Referrals will be triaged based on urgency and complexity: High Priority – Significant functional impairment, safeguarding concerns, or acute mental health issues, Routine Priority – No immediate risk but consistent with possible ASC symptoms, Low Priority – Unclear or inconsistent presentation, Eligibility Criteria: BrightPath Neuro will proceed with an ASC assessment if the following criteria are met: The patient demonstrates clinically significant symptoms consistent with ASC. Symptoms have been present from early childhood. Symptoms are not better explained by another mental health condition or developmental disorder.

5.2 Pre-Assessment Screening

At BrightPath Neuro, pre-assessment screening is an essential step in identifying individuals at risk of autism spectrum conditions (ASC). A range of validated tools may be used depending on age and clinical presentation. The Modified Checklist for Autism in Toddlers (M-CHAT) is used for children aged 16–30 months to identify early signs of ASC. The Social Communication Questionnaire (SCQ) is suitable for individuals aged 4 years and older and helps screen for communication and social interaction difficulties. The Autism Spectrum Quotient (AQ) is a self-report tool used for those aged 16 and above to assess ASC traits, while the Developmental History Questionnaire is used across all age groups to gather detailed developmental and early social interaction history. If the screening outcome is positive, the patient will be referred for a full diagnostic assessment. If the screening is negative, indicating no significant ASC traits, the patient will be discharged with appropriate advice provided to the referrer.

5.3 Comprehensive Diagnostic Assessment

BrightPath Neuro conducts comprehensive diagnostic assessments for autism spectrum conditions (ASC) using a combination of validated tools and clinical expertise. Key tools include the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), a standardised observational assessment focusing on social communication and repetitive behaviours, and the Autism Diagnostic Interview-Revised (ADI-R), which gathers a detailed developmental history through structured interviews. Additional components may include a developmental and psychiatric history, a sensory profile to assess sensory processing challenges, and cognitive and language assessments, if clinically indicated. Each assessment includes a thorough review of the individual’s developmental history, a parent or carer interview (where relevant), direct observation of social communication, and engagement in structured play or conversational tasks. To ensure comfort and accuracy, assessments are conducted in a quiet, low-stimulation environment, and multiple sessions may be needed to complete the process.

5.4 Diagnostic Outcome and Communication

Diagnostic Report: A full diagnostic report must be completed within 10 working days of the final assessment session. The report should include: Summary of assessment tools used, Clinical findings, Final diagnosis (if applicable)Recommendations for support and intervention, Communication with Patient and Family: The outcome of the assessment should be discussed in person or via video call. The patient and/or family should receive a copy of the diagnostic report. Recommendations for support and next steps should be provided. Post-Diagnostic Support: If a diagnosis of ASC is confirmed, the patient should be referred for: Psychoeducation and parent training (if applicable)Social skills support, Occupational therapy (if indicated)Educational support and EHCP application (if applicable)Referral to Specialist Services: If additional mental health or behavioural support is required, the patient may be referred to: CAMHS (for patients under 18)Adult mental health services, Speech and language therapy, Occupational therapy

5.5 Documentation and Record Keeping

Clinical Records: All assessment findings and reports must be documented in the patient’s clinical record. Records must be retained for 7 years (or until the patient’s 25th birthday for minors).Audit: ASC assessment records will be reviewed during quarterly audits.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and timelines for ASC assessments. The Governance Lead will audit ASC diagnostic outcomes quarterly. Corrective actions will be implemented where assessment failures are identified.

7. Training and Awareness

Staff involved in ASC assessment must complete annual training on: NICE guidelines for ASC diagnosisADOS-2 and ADI-R protocols, Managing sensory sensitivities

8. Responsibilities

Clinical Lead: Oversee ASC assessment and diagnostic procedures. All Assessing Clinicians: Ensure accurate and thorough assessment of ASC.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Prescribing (ASC) Policy (if medication is involved)

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent and prescribing medication for patients diagnosed with Autism Spectrum Condition (ASC) at BrightPath Neuro. While medication is not a first-line treatment for ASC itself, it may be prescribed to manage co-occurring symptoms such as anxiety, aggression, attention difficulties, hyperactivity, or sleep disturbances. BrightPath Neuro is committed to ensuring that all prescribing decisions are made with the patient’s full informed consent and in accordance with clinical guidelines and legal requirements. The purpose of this policy is to: Establish a clear framework for obtaining informed consent when prescribing medication for patients with ASC. Ensure that patients (or their caregivers) understand the benefits, risks, and alternatives to medication. Ensure that prescribing decisions are made in line with clinical best practice and legal requirements. Provide clear guidance for monitoring and reviewing medication prescribed for ASC-related symptoms. Promote a patient-centred and evidence-based approach to medication management.

2. Scope

This policy applies to: All patients diagnosed with ASC at BrightPath Neuro who are prescribed medication. All staff involved in prescribing and medication management, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Pharmacists, Clinical Leads, It covers: Obtaining informed consent for prescribing medication, Medication choices and prescribing decisions, Monitoring and reviewing medication, Documentation and record-keeping, Responding to adverse drug reactions and side effects

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all prescribing decisions are based on clinical evidence and patient need. Providing patients and caregivers with clear, accurate, and unbiased information about medication options. Obtaining informed consent before starting, changing, or discontinuing medication. Monitoring medication effectiveness and side effects regularly. Responding promptly to adverse drug reactions. Ensuring that all prescribing practices comply with national guidelines and legal requirements.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines NG11 – Autism spectrum disorder in under 19s: recognition, referral, and diagnosis, National Institute for Health and Care Excellence (NICE) Guidelines CG128 – Autism spectrum disorder in adults: diagnosis and management, British National Formulary (BNF)Mental Capacity Act 2005Human Rights Act 1998Equality Act 2010Misuse of Drugs Act 1971

5. Procedure

5.1 Principles of Informed Consent

Informed consent is a legal and ethical requirement before prescribing medication. Informed consent requires that the patient (or caregiver) has: Capacity – The ability to understand the information provided and make an informed decision. Information – Clear and accurate information about the medication, including benefits, risks, and alternatives. Voluntariness – Freedom from coercion or pressure when making a decision about medication.

5.2 Determining Capacity to Consent

Assessment of Capacity: Capacity to consent should be assessed based on the principles of the Mental Capacity Act 2005.Capacity assessment should consider: The patient’s ability to understand information about the medication. The patient’s ability to retain and weigh the information. The patient’s ability to communicate their decision. Young People (Under 16): Young people under 16 may give consent if they are judged to have Gillick competence (sufficient understanding and intelligence to make the decision).If a young person is not Gillick competent, consent must be obtained from a parent or legal guardian. Adults Without Capacity: If an adult lacks capacity to consent: A decision may be made in their best interests, following the Mental Capacity Act 2005.The patient’s next of kin or legal guardian should be consulted. An Independent Mental Capacity Advocate (IMCA) may be involved if appropriate.

5.3 Providing Information About Medication

Medication Discussion: Before starting medication, the prescriber must discuss the following with the patient (or caregiver):Name of the medication, Purpose of the medication, Expected benefits and timeline for improvement, Common side effects and how to manage them, Serious side effects (including those requiring urgent medical attention)Potential interactions with other medications or substances, Alternatives to medication (including non-pharmacological options)Risks of not treating the condition, Written Information: Patients and caregivers must be provided with written information about the medication (e.g., Patient Information Leaflet).Written consent must be obtained before starting medication. Documentation: The prescriber must document in the clinical record: That informed consent was obtained, That the patient (or caregiver) understood the information provided, Any questions or concerns raised by the patient or caregiver

5.4 Prescribing Medication

At BrightPath Neuro, medication may be considered to help manage specific symptoms associated with autism spectrum conditions (ASC), following a careful and Individualised approach. For irritability and aggression, antipsychotics such as Risperidone or Aripiprazole may be prescribed, starting at a low dose and titrating gradually. Hyperactivity and inattention may be managed with Methylphenidate or Atomoxetine, with monitoring for potential cardiovascular side effects. Anxiety can be treated using SSRIs, such as Sertraline, initiated at low doses with close monitoring for signs of increased agitation. For sleep disturbances, Melatonin may be prescribed using the lowest effective dose, while monitoring for daytime drowsiness. All medications should be initiated at the lowest effective dose and titrated slowly based on clinical response and side effects. Patients must be offered a follow-up within two weeks of starting any new medication. Where controlled drugs such as Methylphenidate are prescribed, they must comply with the Controlled Drug Prescribing Policy in line with regulatory requirements.

5.5 Monitoring and Reviewing Medication

Frequency of Monitoring: Initial review within 2 weeks of starting medication. Follow-up review every 4–6 weeks during titration. Ongoing monitoring every 3 months for patients on stable medication. Monitoring Parameters: Symptom improvement, Side effects and tolerability, Physical health (blood pressure, heart rate, weight)Psychiatric symptoms (agitation, mood changes)Adjusting Medication: If side effects develop, reduce the dose or switch to an alternative medication. If the medication is ineffective after titration, discontinue and consider alternatives.

5.6 Responding to Adverse Reactions

Mild Side Effects: Provide reassurance and advice to manage symptoms. Monitor symptoms during follow-up. Severe Side Effects: If the patient develops severe agitation, suicidal ideation, or cardiac symptoms: Stop medication immediately. Provide urgent medical care. Report to the Care Quality Commission (CQC) if required.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of prescribing records. The Governance Lead will monitor completion of informed consent forms.

7. Training and Awareness

All prescribing staff must complete annual training on: Informed consent and capacity, Prescribing for neurodevelopmental conditions

8. Responsibilities

Prescribing Clinicians: Ensure informed consent is obtained and documented.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Multi-Disciplinary Team (MDT) Collaboration Policy

1. Purpose

This policy sets out the procedures and guidelines for effective Multi-Disciplinary Team (MDT) collaboration at BrightPath Neuro. BrightPath Neuro recognises that effective MDT collaboration is essential for delivering high-quality, patient-centred care. A coordinated approach involving a range of healthcare professionals ensures that patients receive comprehensive assessments, treatment, and support. MDT working improves clinical decision-making, enhances patient safety, and facilitates the delivery of integrated care. The purpose of this policy is to: Establish a framework for effective MDT collaboration. Define the roles and responsibilities of MDT members. Ensure that patient care plans are developed through a collaborative process. Promote timely and accurate communication within the MDT. Ensure that MDT decision-making is patient-centred and based on clinical evidence.

2. Scope

This policy applies to: All clinical and administrative staff involved in MDT collaboration at BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Clinical Leads, Occupational Therapists, Speech and Language Therapists, Social Workers, Mental Health Nurses, Administrative and Governance Staff, It covers meetings and case reviews, Clinical decision-making processes, Communication within the MDT, Documentation and record-keeping, Monitoring and evaluation of MDT effectiveness

3. Policy Statement

BrightPath Neuro is committed to: Providing a structured framework for effective MDT collaboration. Ensuring that patient care is informed by a range of professional expertise. Promoting open, respectful, and professional communication within the MDT. Ensuring that patients are actively involved in care planning decisions. Maintaining high standards of clinical governance and accountability within the MDT. Ensuring that MDT decisions are based on evidence-based practice and national guidelines.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Mental Capacity Act 2005Children Act 1989 and 2004British Psychological Society (BPS) Guidelines, Royal College of Psychiatrists Guidance, Royal Pharmaceutical Society (RPS) Guidelines, Human Rights Act 1998Equality Act 2010

5. Procedure

5.1 Definition of a Multi-Disciplinary Team (MDT)

At BrightPath Neuro, a Multi-Disciplinary Team (MDT) refers to a collaborative group of healthcare professionals from various specialties who work together to provide coordinated and comprehensive care. MDT members may include a Medical Practitioner, who leads clinical assessments, oversees treatment plans, and offers medical oversight, and a Non-Medical Prescriber (NMP), responsible for prescribing medication, adjusting doses, and monitoring effects. A Clinical Psychologist conducts assessments and delivers therapeutic interventions, while a Clinical Pharmacist provides guidance on medication interactions, side effects, and treatment planning. An Occupational Therapist supports functional and sensory needs, and a Speech and Language Therapist assists with communication and language development. A Mental Health Nurse offers support for emotional regulation and mental health concerns, and a Social Worker evaluates the social and environmental factors influencing the patient's wellbeing. Administrative and governance staff ensure efficient scheduling, accurate record-keeping, and compliance with relevant policies.

5.2 MDT Meeting Structure

Frequency of Meetings: Regular MDT meetings must be held weekly. Urgent cases may require ad hoc MDT meetings. Meeting Format: Meetings may be conducted in person or via secure video conferencing. Meetings must be scheduled with at least 5 working days’ notice unless urgent. Chairing of Meetings: MDT meetings should be chaired by the

Clinical Lead or a designated senior clinician. The chair is responsible for ensuring that all voices are heard and that decisions are recorded. Attendance: Attendance at MDT meetings is mandatory for relevant staff involved in the patient’s care. Staff unable to attend must provide a written update before the meeting.

5.3 Case Discussion and Decision-Making

Presentation of Cases: The case lead (e.g., assessing clinician) will present a summary of the case, including: Medical and psychological history, Current symptoms and clinical findings, Assessment outcomes, Current treatment plan, Social and environmental factors, Relevant diagnostic tools and reports (e.g., ADOS-2, ADI-R, cognitive assessments) should be shared. Discussion: MDT members will discuss the case from their professional perspective. The discussion should include: Symptom management, Medication options and adjustments, Psychological and behavioural interventions, Risk factors and safeguarding concerns, Patient and caregiver feedback, All participants are encouraged to contribute equally and without bias. Consensus Decision-Making: Decisions must be made by consensus wherever possible. Where consensus cannot be reached, the Clinical Lead or Chair will make the final decision based on clinical evidence and professional guidelines. Decisions must prioritise patient safety and well-being.

5.4 Care Planning and Implementation

Development of Care Plan: Following the MDT discussion, a formal care plan will be developed. The care plan should include: Diagnosis and clinical formulation, Medication and treatment recommendations, Psychological and behavioural interventions, Occupational and social support needs, Communication strategies and educational support (if applicable)Risk management and safeguarding plans, Patient and Caregiver Involvement: The care plan should be discussed with the patient and/or caregivers. Consent should be obtained before implementing any interventions. Patients should have the opportunity to ask questions and provide input. Implementation and Monitoring: The case lead will be responsible for implementing the care plan. Progress will be monitored at follow-up MDT meetings. Adjustments to the care plan should be discussed and agreed upon by the MDT.

5.5 Documentation and Record-Keeping

Meeting Minutes: Formal minutes must be recorded for each MDT meeting. Minutes must include: List of attendees, Summary of cases discussed, Clinical decisions made, Actions assigned and deadlines, Minutes must be stored securely and made available to all MDT members. Patient Records: All MDT decisions and care plans must be recorded in the patient’s clinical record. Records must be retained for 7 years (or until the patient’s 25th birthday for minors).

5.6 Escalation and Dispute Resolution

Escalation: Complex cases or unresolved disagreements should be escalated to the Clinical Governance Committee. Safeguarding concerns must be reported immediately to the Safeguarding Lead. Dispute Resolution: Where consensus cannot be reached, the Clinical Lead or Chair will make the final decision. If disagreement persists, external mediation may be sought.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of MDT decisions and care plans. The Governance Lead will monitor attendance and participation at MDT meetings. Findings will be presented to the Clinical Governance Committee for review.

7. Training and Awareness

All MDT members must complete annual training on: MDT collaboration principles, Effective communication and conflict resolution, Clinical decision-making and risk assessment

8. Responsibilities

Clinical Lead: Oversee the MDT process and ensure policy compliance. All MDT Members: Actively contribute to MDT discussions. Follow agreed care plans and clinical decisions.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Communication and Sensory Needs Policy

1. Purpose

This policy sets out the procedures and guidelines for identifying, assessing, and supporting the communication and sensory needs of patients at BrightPath Neuro. BrightPath Neuro recognises that individuals with neurodevelopmental conditions, including Autism Spectrum Condition (ASC), Attention Deficit Hyperactivity Disorder (ADHD), and other complex mental health or developmental needs, may have challenges with communication and sensory processing. Meeting these needs is essential to providing effective, patient-centred care and ensuring that patients feel understood and supported. The purpose of this policy is to: Ensure that the communication and sensory needs of patients are identified and supported. Provide staff with clear guidance on adapting communication methods based on individual needs. Ensure that the environment at BrightPath Neuro is sensory-friendly and accessible. Ensure that reasonable adjustments are made to support patients with communication and sensory needs. Ensure compliance with national guidelines and professional standards related to communication and sensory processing.

2. Scope

This policy applies to: All patients receiving care at BrightPath Neuro, including but not limited to: Children, adolescents, and adults with neurodevelopmental disorders (e.g., ASC, ADHD)Patients with speech and language difficulties, Patients with sensory processing difficulties, Patients with hearing, vision, or cognitive impairments, All staff involved in patient care and communication, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Speech and Language Therapists (SLTs)Occupational Therapists, Mental Health Nurses, Healthcare Assistants, Administrative and Reception Staff, It covers: Communication and sensory assessments, Development of communication and sensory support plans, Environmental adjustments to support sensory needs, Use of alternative communication methods, Staff training and awareness

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that communication and sensory needs are assessed and supported for all patients. Providing patients with accessible information about their care. Ensuring that reasonable adjustments are made to support communication and sensory processing. Creating a sensory-friendly and inclusive care environment. Training staff to identify and respond effectively to communication and sensory challenges.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, National Institute for Health and Care Excellence (NICE) Guidelines NG11 – Autism spectrum disorder in under 19s: recognition, referral, and diagnosis, National Institute for Health and Care Excellence (NICE) Guidelines NG87 – Attention deficit hyperactivity disorder: diagnosis and management, Mental Capacity Act 2005Children Act 1989 and 2004Equality Act 2010Human Rights Act 1998British Psychological Society (BPS) Guidelines, Royal College of Speech and Language Therapists (RCSLT) Guidelines, Royal College of Occupational Therapists (RCOT) Guidelines

5. Procedure

5.1 Identification and Assessment of Communication and Sensory Needs

At BrightPath Neuro, communication and sensory needs are assessed as part of the initial assessment process to ensure personalised and inclusive care. Patients or caregivers are asked about preferred communication methods, sensory sensitivities (such as to noise, light, or texture), use of assistive devices like hearing aids, and support required for understanding information. Any identified needs are recorded in the patient’s clinical record. To support this, a range of screening tools may be used, including the Sensory Profile to evaluate sensory processing, Speech and Language Assessments for communication skills, Visual Schedule Assessments for visual aid needs, and Hearing Screening to identify auditory support requirements. Where complex needs are identified, appropriate referrals should be made—to Speech and Language Therapy (SLT) for communication issues, Occupational Therapy (OT) for sensory processing, Audiology for hearing concerns, and Vision Services for visual impairments.

5.2 Development of Communication and Sensory Support Plans

Personalised Communication Plan: A personalised communication plan should be developed for patients with identified communication needs. The plan should include: Preferred communication method (e.g., verbal, sign language, communication device)Use of augmentative and alternative communication (AAC) systems, Strategies for improving understanding and processing information, Support for emotional regulation linked to communication challenges, Personalised Sensory Plan: A personalised sensory plan should be developed for patients with sensory processing difficulties. The plan should include: Environmental modifications (e.g., lighting, noise reduction)Sensory tools (e.g., weighted blankets, noise-cancelling headphones)Activity planning to manage sensory overload, Strategies for managing emotional regulation linked to sensory challenges, Patient and Caregiver Involvement: The patient (or caregiver) must be involved in the development of the plan. Plans should be updated annually or sooner if the patient’s needs change.

5.3 Communication and Sensory-Friendly Environment

Physical Environment: Clinics should be designed to support sensory-friendly care, including: Low lighting in consultation rooms, Noise reduction (e.g., soft furnishings, soundproofing)Calm and neutral colour schemes, Clear signage using symbols and large fonts, Waiting Areas: Designated quiet areas should be provided. Patients should have access to sensory tools (e.g., fidget toys).Flexible appointment scheduling should be available to avoid busy times. Communication Aids: BrightPath Neuro will provide communication aids, including: Visual schedules, Picture Exchange Communication System (PECS)Communication boards, Assistive technology (e.g., text-to-speech)

5.4 Staff Communication with Patients

Verbal Communication: Staff should: Use simple, clear language. Speak slowly and allow time for processing. Avoid jargon and medical terms. Use positive and reassuring body language. Non-Verbal Communication: Staff should use visual aids and gestures where appropriate. Staff should maintain appropriate eye contact. Alternative Communication Methods: Staff should use alternative communication methods based on patient preference, including: British Sign Language (BSL)Communication devices, Written materials

5.5 Responding to Sensory Overload and Distress

Signs of Sensory Overload: Patients experiencing sensory overload may: Become agitated or distressed, Display repetitive behaviours (e.g., rocking, hand-flapping)Attempt to leave the environment, Response: Staff should: Remove the patient from the triggering environment. Offer sensory calming tools (e.g., headphones).Reduce noise and lighting where possible. Use calming communication techniques.

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of communication and sensory support plans. The Governance Lead will monitor staff compliance with communication protocols.

7. Training and Awareness

All staff must complete annual training on: Communication techniques for neurodivergent patients, Sensory processing disorders, Use of communication aids and alternative methods

8. Responsibilities

Clinical Lead: Ensure communication and sensory support plans are implemented. All Staff: Follow communication and sensory protocols.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Reasonable Adjustments Policy

1. Purpose

This policy sets out the procedures and guidelines for identifying, implementing, and monitoring reasonable adjustments at BrightPath Neuro to ensure that all patients receive equitable access to care and support. BrightPath Neuro is committed to ensuring that individuals with disabilities, neurodevelopmental conditions, or additional needs are not disadvantaged when accessing services. Reasonable adjustments are essential to ensuring that the physical environment, communication methods, and care delivery are accessible to all individuals, in line with legal and professional standards. The purpose of this policy is to: Ensure that all patients have equal access to services and support. Establish a clear framework for identifying and implementing reasonable adjustments. Ensure that staff are trained and aware of their responsibilities to provide reasonable adjustments. Ensure compliance with legal and professional requirements for equality and access to healthcare. Create an inclusive and patient-centred care environment.

2. Scope

This policy applies to: All patients receiving care at BrightPath Neuro, including but not limited to: Patients with physical disabilities, Patients with sensory impairments (e.g., hearing or vision loss)Patients with neurodevelopmental conditions (e.g., Autism Spectrum Condition (ASC), ADHD)Patients with mental health conditions, Patients with cognitive impairments, Patients with communication difficulties, Patients with language barriers, All staff involved in patient care and service delivery, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Occupational Therapists, Speech and Language Therapists, Mental Health Nurses, Healthcare Assistants, Administrative and Governance Staff, It covers: Identification and assessment of need for reasonable adjustments, Physical, communication, and service delivery adjustments, Staff training and awareness, Monitoring and compliance

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that all patients receive equitable access to care and support. Making reasonable adjustments to accommodate individual needs. Promoting a patient-centred and inclusive approach to care. Providing training and support to staff on delivering reasonable adjustments. Removing barriers that prevent patients from accessing care. Maintaining compliance with equality and human rights legislation.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Equality Act 2010 – Requirement for service providers to make reasonable adjustments for individuals with disabilities. Mental Capacity Act 2005Human Rights Act 1998Children Act 1989 and 2004General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, British Psychological Society (BPS) Guidelines, Royal College of Occupational Therapists (RCOT) Guidelines, Royal College of Speech and Language Therapists (RCSLT) Guidelines

5. Procedure

5.1 Definition of Reasonable Adjustments

Under the Equality Act 2010, reasonable adjustments are defined as changes that must be made to remove or reduce barriers faced by individuals with disabilities when accessing healthcare services. Reasonable adjustments may include: Physical adjustments – Changes to the physical environment to improve access. Communication adjustments – Providing information in an accessible format or using alternative communication methods. Service delivery adjustments – Flexibility in appointment scheduling, staffing, and treatment planning. Reasonable adjustments must be: Proportionate – Appropriate to the individual’s needs and the organisation’s capacity. Effective – The adjustment must improve access to care. Legally compliant – The adjustment must meet legal requirements under the Equality Act 2010.

5.2 Identification of Need for Reasonable Adjustments

Initial Assessment: Reasonable adjustments should be identified during the initial patient assessment. The assessing clinician should ask about: Mobility issues and physical accessibility needs, Communication preferences and challenges, Sensory processing difficulties (e.g., light, noise)Cognitive or learning needs, Cultural or religious considerations, Emotional or psychological needs, Patient-Centered Approach: Patients (or their caregivers) should be actively involved in identifying adjustments. Staff should explore adjustments with sensitivity and avoid making assumptions about patient needs. Referral to Specialist Services: If a specialist assessment is required, patients should be referred to: Occupational Therapy (OT)Speech and Language Therapy (SLT)Audiology Vision Services

5.3 Types of Reasonable Adjustments

5.3.1 Physical Adjustments

Examples of physical adjustments include: Step-free access at entrances and within the building, Adjustable seating or examination beds, Accessible toilet facilities, Reserved parking spaces for disabled patients, Quiet rooms or sensory-friendly waiting areas

5.3.2 Communication Adjustments

Examples of communication adjustments include: Use of alternative communication methods, including: British Sign Language (BSL) interpreters, Makaton, Picture Exchange Communication System (PECS)Written materials in large print or Braille, Provision of information in different formats (e.g., audio, easy read)Allowing extra time for appointments to support communication processing

5.3.3 Service Delivery

Adjustments, Examples of service delivery adjustments include: Flexible appointment scheduling (e.g., avoiding busy times)Allowing carers or support workers to attend appointments, Adjusting the environment (e.g., low lighting, noise reduction)Use of sensory tools (e.g., weighted blankets, fidget toys)Extending appointment times for patients with processing or sensory difficulties

5.4 Implementation of Adjustments

Development of a Reasonable Adjustment Plan: Reasonable adjustments should be documented in the patient’s clinical record. The plan should include: Type of adjustment, Implementation method, Review date, Patient consent (if applicable)Communication of Adjustments: All relevant staff involved in the patient’s care should be informed of the adjustments. Adjustments should be communicated during handovers and MDT meetings. Review and Modification: Adjustments should be reviewed regularly (at least every 6 months).Adjustments should be modified if the patient’s needs change.

5.5 Monitoring and Compliance

Incident Reporting: If a reasonable adjustment is not made or is ineffective, this must be reported using the Incident Reporting Policy. Audit and Review: The Clinical Lead will conduct quarterly audits to ensure adjustments are being implemented and are effective. The Governance Lead will monitor compliance with legal and professional standards.

6. Staff Training and Awareness

All staff must complete annual training on: Legal and ethical requirements for reasonable adjustments, Identifying and responding to communication and sensory needs, Implementing physical, communication, and service delivery adjustments, Promoting equality and reducing barriers to care

7. Responsibilities

Clinical Lead: Ensure reasonable adjustments are assessed and implemented correctly. Monitor compliance with the policy. Governance Lead: Oversee audits and incident reporting. Ensure adjustments meet legal and professional standards. All Staff: Identify patient needs and implement appropriate adjustments. Ensure adjustments are communicated effectively across the team.

8. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Refund Policy

Introduction At Brightpath Neuro, we strive to provide high-quality neurodiversity and mental health services. We understand that circumstances may arise where you need to cancel or request a refund for a service. This Refund Policy outlines the terms and conditions under which refunds are granted for services provided by Brightpath Neuro.

 👉 Submit a Refund Request

2. Scope This policy applies to all services offered by Brightpath Neuro, including but not limited to: ADHD, Autism (ASC), and Dyslexia Assessments Sleep Assessments Weight Management Services Mood and Mental Health Support

3. Eligibility for Refund Refunds are available under the following circumstances:

3.1 Cancellation by Brightpath Neuro If Brightpath Neuro cancels a service due to unforeseen circumstances or staff availability, you will be offered the option to: Reschedule the appointment at no additional cost, OR Receive a full refund within 7 business days of the cancellation.

3.2 Client Cancellation You may cancel a booking and be eligible for a refund under the following terms: Cancellation Period Refund Amount More than 48 hours before the appointment100% refund Within 24 to 48 hours before the appointment50% refund Less than 24 hours before the appointment or failure to attend No refund If you cancel due to a medical emergency or other extenuating circumstances, Brightpath Neuro may offer a full or partial refund at the discretion of the management team. Supporting documentation (e.g., medical certificate) may be requested. 3.3 Dissatisfaction with Service If you are dissatisfied with the service provided, you must notify Brightpath Neuro in writing within 5 working days of the appointment. A full or partial refund may be granted if: The service was not delivered as described. There was a significant error in the assessment or report. The service did not meet professional or contractual standards. Refund requests will be reviewed by senior management, and a decision will be communicated within 10 business days.

3.4 Technical Issues (Online Services) If you experience technical issues during an online assessment or consultation that prevent the completion of the service, you may be eligible for a partial or full refund depending on the extent of the disruption. A full refund will be issued if the service cannot be rescheduled or completed due to technical issues caused by Brightpath Neuro.

No refund will be issued if the technical issue is due to the client’s equipment or internet connection.

4. Non-Refundable Circumstances Refunds will not be granted in the following cases: If you fail to attend an appointment without prior notice. If you cancel less than 24 hours before the appointment (unless under exceptional circumstances). If the service was completed as described and in line with professional standards. If you disagree with the outcome of a professional assessment but the process and delivery were conducted in line with best practices. If you fail to provide necessary information or documentation required to complete the service.

5. How to Request a Refund To request a refund, you must contact us via: Email: [email protected] Phone: +44 20 3856 8602 Please include the following details in your refund request: Full name Date of service Reason for refund request Supporting documents (if applicable)

6. Processing Refunds Approved refunds will be processed within

7 business days of the decision. Refunds will be issued using the original payment method. If the original payment method is unavailable, an alternative refund method will be agreed upon with the client. 7. Disputed Refunds If you disagree with the outcome of a refund request, you may escalate the matter by contacting the Director of Clinical Services at Brightpath Neuro. A review will be conducted within 10 business days, and the outcome will be communicated in writing. If you remain dissatisfied, you may contact the relevant regulatory body (e.g., Care Quality Commission (CQC)) for further resolution.

8. Statutory Rights This Refund Policy does not affect your statutory rights under the Consumer Rights Act 2015 or other applicable laws.

9. Policy Review This policy will be reviewed annually to ensure compliance with UK consumer protection laws and healthcare regulations. Any updates or changes will be communicated to clients through our website and booking confirmation materials..

Patients Rights and Responsibilities Policy

1. Purpose

This policy sets out the rights and responsibilities of patients receiving care at BrightPath Neuro. BrightPath Neuro is committed to providing high-quality, patient-centred care in a safe, respectful, and non-discriminatory environment. Recognising and respecting patient rights is essential to ensuring that patients feel valued, understood, and empowered. Equally, patients have responsibilities to support the effective delivery of care and ensure a positive, respectful care environment for all. The purpose of this policy is to: Ensure that patients are aware of their legal and ethical rights when receiving care. Encourage patients to actively participate in their care. Ensure that patients understand their responsibilities in maintaining a respectful and supportive environment. Provide a framework for addressing violations of patient rights and responsibilities.

2. Scope

This policy applies to: All patients receiving care at BrightPath Neuro. All caregivers, family members, and advocates involved in the patient’s care. All staff providing care and support at BrightPath Neuro. It covers: Patient rights related to care, communication, and confidentiality. Patient responsibilities related to behaviour, communication, and participation in care. Resolution of conflicts related to patient rights and responsibilities.

3. Policy Statement

BrightPath Neuro is committed to: Treating all patients with dignity and respect. Providing equal access to care and support for all patients. Encouraging shared decision-making between patients and healthcare providers. Protecting patient confidentiality and privacy. Providing patients with opportunities to give feedback and make complaints. Promoting a safe and respectful care environment.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Human Rights Act 1998Mental Capacity Act 2005Equality Act 2010General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, National Institute for Health and Care Excellence (NICE) Guidelines, Data Protection Act 2018 (UK GDPR)

5. Procedure

5.1 Patient Rights

Patients at BrightPath Neuro have the following rights: Right to Dignity and Respect, Patients have the right to be treated with dignity and respect. Patients must not be discriminated against based on: Age, Gender, Race or ethnicity, Religion or belief, Disability, Sexual orientation, Socioeconomic status, Gender identity, Right to Confidentiality and Privacy, Patients have the right to confidentiality of their medical information. Personal data will only be shared with other healthcare providers when: Consent is given. Disclosure is necessary to protect the patient or others from harm. Disclosure is required by law. Right to Access Information, Patients have the right to access information about their care. Information should be provided in a format that meets the patient’s communication needs (e.g., large print, easy read).Patients have the right to access their medical records upon request. Right to Informed Consent, Patients have the right to make decisions about their care. Healthcare providers must explain: The diagnosis and available treatment options. The risks and benefits of treatment. Alternative treatment options. Patients have the right to refuse treatment. Right to Safety and Protection, Patients have the right to receive care in a safe and secure environment. Patients have the right to be protected from: Abuse and neglect, Harassment and intimidation, Discrimination, Right to Feedback and Complaint Resolution, Patients have the right to provide feedback about their care. Patients have the right to make complaints without fear of retaliation. Complaints must be investigated and resolved within 30 days.

5.2 Patient Responsibilities

Patients at BrightPath Neuro have the following responsibilities: Provide Accurate Information, Patients must provide accurate and complete information about: Medical history, Current medications, Allergies, Lifestyle factors (e.g., smoking, alcohol use)Follow Treatment Plans, Patients are expected to follow the agreed treatment plan. If the patient chooses not to follow the plan, they should notify their clinician. Respect Staff and Other Patients, Patients must treat staff and other patients with respect and courtesy. Harassment, discrimination, and aggression will not be tolerated. Attend Appointments, Patients are expected to attend scheduled appointments. If they cannot attend, they should provide at least 24 hours' notice. Medication and Safety, Patients must take medication as prescribed. Patients should report side effects or medication errors immediately. Feedback and Complaints, Patients should provide feedback in a respectful manner. Complaints should be submitted through the Complaints and Feedback Policy.

5.3 Resolution of Conflicts

Informal Resolution: Minor issues should be resolved through discussion with the clinical team. Formal Complaints: Serious concerns should be addressed through the Complaints and Feedback Policy. Legal Recourse: If a conflict cannot be resolved internally, patients have the right to seek independent legal advice.

6. Monitoring and Compliance

The Clinical Lead will monitor patient complaints and feedback. The Governance Lead will review compliance with patient rights policies. Issues of non-compliance will be reported to the Clinical Governance Committee.

7. Training and Awareness

All staff must complete annual training on: Patient rights and responsibilities, Data protection and confidentiality, Communication and conflict resolution

8. Responsibilities

Clinical Lead: Ensure patient rights and responsibilities are communicated and upheld. Monitor adherence to this policy. Governance Lead: Investigate complaints and take corrective action where needed. All Staff: Treat patients with dignity and respect. Respond to patient concerns and feedback.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Incident Reporting and Investigation Policy

1. Purpose

This policy sets out the procedures and guidelines for reporting and investigating incidents at BrightPath Neuro. BrightPath Neuro recognises that effective incident reporting and investigation are essential for maintaining patient safety, improving the quality of care, and preventing future adverse events. Open and transparent reporting ensures that incidents are identified and addressed promptly, lessons are learned, and improvements are implemented to prevent recurrence. The purpose of this policy is to: Establish a clear framework for reporting and investigating incidents. Ensure that incidents are managed in a timely, structured, and transparent manner. Promote a culture of openness and learning. Ensure that incidents are used as opportunities for improving patient care and service delivery. Ensure compliance with legal and professional standards for incident reporting and investigation.

2. Scope

This policy applies to: All staff employed by BrightPath Neuro, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Clinical Pharmacists, Occupational Therapists, Speech and Language Therapists, Mental Health Nurses, Healthcare Assistants Administrative and Governance Staff, All incidents involving: Patients, Caregivers and families, Staff members, Contractors and visitors, It covers: Clinical and non-clinical incidents, Medication-related incidents, Safeguarding incidents, Data breaches, Patient complaints linked to incidents, Serious incidents and near misses

3. Policy Statement

BrightPath Neuro is committed to: Creating a culture of openness and transparency where incidents are reported without fear of blame or punishment. Encouraging staff to report incidents promptly and accurately. Ensuring that all reported incidents are investigated thoroughly and fairly. Protecting the confidentiality of staff and patients involved in incidents. Using incident findings to improve patient care and prevent future occurrences. Complying with national and professional standards for incident reporting and investigation.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Professional Standards, Nursing and Midwifery Council (NMC) Code of Conduct, Data Protection Act 2018 (UK GDPR)Mental Capacity Act 2005National Reporting and Learning System (NRLS) Guidelines, Serious Incident Framework (NHS England)Royal Pharmaceutical Society (RPS) Guidelines, British Psychological Society (BPS) Guidelines, Human Rights Act 1998Equality Act 20105.

Procedure

5.1 Definition of an Incident

An incident is any event or circumstance that results in or has the potential to result in: Harm to a patient, caregiver, or staff member, Breach of confidentiality or data security, Damage to property or loss of assets, Failure to deliver expected standards of care

5.2 Types of Incidents

At BrightPath Neuro, various types of incidents may occur and must be promptly identified, reported, and addressed to ensure patient safety and service quality. These incidents include clinical incidents such as medication errors, missed diagnoses, or adverse reactions; safeguarding incidents, including physical abuse, neglect, or unexplained injuries; and patient safety incidents, such as falls, incorrect procedures, or pressure injuries. Medication errors may involve the administration of the wrong dose, incorrect medication, or missed doses. Data breaches encompass unauthorised access to patient records or the loss of sensitive information. Environmental incidents include issues such as fire, flooding, or equipment failure, while violence and aggression may involve physical altercations or verbal threats directed at staff. Additionally, near misses—events that did not cause harm but had the potential to do so—are also considered important for review and learning.

5.3 Immediate Response to an Incident

Ensure Safety: Remove any immediate risk to the patient, staff, or environment. Provide immediate care or first aid if required. Contact emergency services if necessary. Preserve Evidence: Do not move or alter equipment involved in the incident unless it poses a safety risk. Record the names of any witnesses. Report the Incident: All incidents must be reported within 24 hours using the Incident Reporting Form. If the incident involves a safeguarding concern, notify the Designated Safeguarding Lead immediately. Notify Management: The Clinical Lead and Governance Lead must be informed of serious incidents within 24 hours.

5.4 Reporting an Incident

Who Can Report an Incident: All staff have a duty to report incidents. Patients and caregivers can also report incidents to staff. Completing the Incident Report Form: The report should include: Date and time of the incident, Location of the incident, Description of the incident (facts only)Actions taken immediately following the incident, Names of those involved, Name of person completing the report, Submission: Completed forms should be submitted to the Governance Lead. Serious incidents should be reported directly to the Care Quality Commission (CQC).

5.5 Investigation Process

Initial Review: The Clinical Lead or Governance Lead will review the report within 24 hours. If the incident is serious, a formal investigation will be initiated. Investigation Team: An investigation team may include: Clinical Lead, Governance Lead, Safeguarding Lead (if applicable)External specialists (if required)Information Gathering: The investigation should involve: Reviewing patient records, Interviewing staff and witnesses, Examining equipment involved (if applicable)Analysing environmental factors, Root Cause Analysis (RCA):The investigation team will conduct an RCA to: Identify the underlying causes of the incident, Determine whether it was preventable, Identify contributing factors, Outcome and Findings: A formal report will be prepared, including: Summary of the incident, Findings from the investigation, Recommendations for corrective action, Notification: Affected parties (e.g., patient, caregiver) must be informed of the findings. Serious incidents must be reported to the CQC and National Reporting and Learning System (NRLS) within 3 days.

5.6 Corrective Actions and Learning

Implementing Corrective Actions: The Clinical Lead will oversee the implementation of corrective actions. Corrective actions may include: Additional staff training, Process changes, Equipment replacement, Enhanced monitoring, Monitoring: The Governance Lead will monitor the effectiveness of corrective actions. Follow-up audits will be conducted within 3 months of implementing changes. Sharing Learning: Key learning points will be shared with staff through: Clinical team meetings, Newsletters and staff bulletins, Training sessions

6. Monitoring and Compliance

The Governance Lead will maintain a register of all reported incidents. The Clinical Governance Committee will review incident trends quarterly. Serious incidents will be reported to the CQC and NRLS.

7. Training and Awareness

All staff must complete annual training on: Incident reporting and investigation, Root cause analysis (RCA)Responding to patient safety incidents

8. Responsibilities

Clinical Lead: Ensure incident reports are investigated promptly. Ensure corrective actions are implemented. Governance Lead: Monitor incident trends and compliance. Report serious incidents to the CQC.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (for dyslexia assessments)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for dyslexia at BrightPath Neuro. Dyslexia is a specific learning difficulty (SpLD) that affects reading, spelling, and writing. Early identification and diagnosis of dyslexia are essential for providing effective educational and psychological support. BrightPath Neuro is committed to offering a structured, evidence-based approach to assessing dyslexia to ensure that individuals receive appropriate support and intervention to improve academic outcomes and overall well-being. The purpose of this policy is to: Establish a clear framework for the initial assessment and screening of dyslexia. Ensure that assessments are conducted using validated tools and evidence-based guidelines. Provide a patient-centred approach to dyslexia assessment and support. Ensure that findings from the assessment are communicated clearly to the patient and caregivers. Ensure that appropriate follow-up care and support are provided based on assessment findings.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for a dyslexia assessment, including: Children and young people (age 7+)Adults seeking assessment for work or educational purposes, All staff involved in the dyslexia assessment process, including but not limited to: Educational Psychologists, Clinical Psychologists, Speech and Language Therapists, Occupational Therapists, Specialist Dyslexia Assessors, Administrative and Governance Staff, It covers: Referral and triage, Screening and pre-assessment process, Formal diagnostic assessment, Communication of findings and next steps

3. Policy Statement

BrightPath Neuro is committed to: Providing an evidence-based, structured approach to dyslexia assessment and diagnosis. Ensuring that assessments are conducted by appropriately trained and qualified staff. Promoting a patient-centred and strengths-based approach to dyslexia assessment. Ensuring that patients and caregivers understand the assessment process and outcomes. Ensuring that individuals with dyslexia receive appropriate educational, psychological, and occupational support.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Equality Act 2010 – Duty to make reasonable adjustments for individuals with disabilities, including specific learning difficulties (SpLD).Special Educational Needs and Disability (SEND) Code of Practice 2015British Dyslexia Association (BDA) Guidelines, Joint Council for Qualifications (JCQ) Regulations – Guidance for exam arrangements for students with dyslexia. General Medical Council (GMC) Professional Standards, Data Protection Act 2018 (UK GDPR)Education Act 1996

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for dyslexia assessment may come from: Schools and educational professionals, General Practitioners (GP)Occupational health providers, Self-referral (if aged 18+)CAMHS or mental health services, Initial Review: All referrals will be reviewed by the Clinical Lead or a Specialist Dyslexia Assessor within 5 working days of receipt. The referral should include: Reason for referral, Academic and developmental history, Relevant medical history, Previous educational reports (if available)Eligibility Criteria: A dyslexia assessment will be offered if: There is evidence of difficulty with reading, writing, spelling, or processing. Symptoms are not fully explained by other factors (e.g., intellectual disability, mental health condition).The individual meets the minimum age requirement (age 7+).Non-Eligibility: If the referral is declined, the referrer and patient will be informed within 5 working days with an explanation. Alternative support options or referrals will be suggested where appropriate.

5.2 Pre-Assessment Screening

At BrightPath Neuro, pre-assessment screening for dyslexia is conducted to gather essential background information and determine whether a full diagnostic assessment is warranted. A range of validated tools may be used depending on the individual’s age. These include the British Dyslexia Association Checklist for those aged 7 and above, the Lucid Rapid Dyslexia Screening Test for ages 7–16, the Dyslexia Screening Test (DST) for individuals aged 6 and over, the Adult Dyslexia Checklist for those aged 16 and above, and the Phonological Awareness Screening Test, which can be used across all age groups to assess phonological processing and literacy skills. If the results indicate a high likelihood of dyslexia, the individual will be offered a full diagnostic assessment. If dyslexia is not indicated, other potential causes of learning difficulties will be considered and explored.

5.3 Diagnostic Assessment

At BrightPath Neuro, a comprehensive diagnostic assessment for dyslexia involves the use of validated tools to evaluate various aspects of learning and cognitive functioning. These include the Wechsler Individual Achievement Test (WIAT) to assess reading, spelling, writing, and comprehension; the Comprehensive Test of Phonological Processing (CTOPP) to examine phonological awareness, memory, and naming skills; and the Woodcock-Johnson Tests of Cognitive Abilities, which explore cognitive processing and learning difficulties. Additional tools such as the Wide Range Achievement Test (WRAT) and the Gray Oral Reading Test (GORT) are used to measure academic performance and reading proficiency. The assessment process includes a thorough review of developmental and academic history, cognitive and phonological testing, and literacy assessments covering reading, spelling, and writing. Where appropriate, assessments of oral language, working memory, processing speed, and visual-motor integration may also be conducted. To ensure optimal conditions, assessments take place in a quiet, low-stimulation environment, and may be split across multiple sessions to accommodate the individual's needs.

5.4 Diagnostic Outcome and Communication

Diagnostic Report: A full diagnostic report must be completed within 14 working days of the final assessment session. The report should include: Summary of assessment tools used, Clinical findings, Diagnosis (if applicable)Recommendations for support and intervention, Recommendations for educational accommodations (if applicable)Communication with Patient and Caregivers: The outcome of the assessment should be discussed with the patient and/or caregiver. Recommendations for support and next steps should be provided. If a diagnosis of dyslexia is not confirmed, alternative support options should be discussed.

5.5 Post-Assessment Support

Educational Support: Recommendations for educational accommodations will be provided in line with JCQ guidelines. Where indicated, an Education, Health and Care Plan (EHCP) may be recommended. Psychological and Emotional Support: If dyslexia is contributing to emotional or mental health difficulties, referrals to psychological services may be offered. Occupational Therapy and Speech and Language Support: If motor or language difficulties are identified, referrals will be made to relevant services.

6. Monitoring and Compliance

The Clinical Lead will monitor the completion of dyslexia assessments and reports. The Governance Lead will conduct quarterly audits of dyslexia assessment outcomes and recommendations.

7. Training and Awareness

All staff conducting dyslexia assessments must complete training in: Dyslexia diagnostic criteria and assessment tools, Educational support for dyslexia, Emotional and psychological impact of dyslexia

8. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Policy Data Protection and Confidentiality Policy (for dyslexia)

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent, managing data protection, and ensuring confidentiality for patients undergoing dyslexia assessments at BrightPath Neuro. As dyslexia assessments often involve sensitive educational, psychological, and medical information, BrightPath Neuro is committed to ensuring that consent is obtained appropriately, and that all data is managed securely in accordance with legal and professional standards. The purpose of this policy is to: Establish a clear framework for obtaining informed consent prior to dyslexia assessments. Ensure patients understand the nature, purpose, and potential outcomes of their assessment. Ensure that patient data is managed securely and confidentially in line with GDPR and ICO guidelines. Promote a patient-centred, transparent approach to dyslexia assessment.

2. Scope

This policy applies to: All patients referred for a dyslexia assessment at BrightPath Neuro. All staff involved in dyslexia assessments, including but not limited to: Educational Psychologists, Clinical Psychologists, Specialist Dyslexia Assessors, Occupational Therapists, Speech and Language Therapists, Administrative and Governance Staff, It covers: Obtaining informed consent for dyslexia assessments, Consent for information sharing and data processing, Data security, confidentiality, and information management, Patient rights regarding data access and consent withdrawal

3. Policy Statement

BrightPath Neuro is committed to: Ensuring patients understand their rights when providing consent. Explaining clearly the purpose, risks, and outcomes of dyslexia assessments. Protecting patient data with robust security measures. Complying with data protection laws, including the UK GDPR and Data Protection Act 2018.Ensuring that patients’ personal and sensitive data is kept secure and confidential.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: General Data Protection Regulation (UK GDPR)Data Protection Act 2018Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Mental Capacity Act 2005Special Educational Needs and Disability (SEND) Code of Practice 2015Equality Act 2010British Dyslexia Association (BDA) Guidelines, Joint Council for Qualifications (JCQ) Access Arrangements Guidance, Information Commissioner's Office (ICO) Guidance

5. Procedure

5.1 Obtaining Informed Consent for Dyslexia Assessments

Initial Discussion: Before commencing a dyslexia assessment, the assessing clinician must: Explain the purpose of the assessment. Describe the assessment process, including the tools that will be used. Discuss potential outcomes and possible implications. Highlight how results may impact educational, employment, or legal support. Explain the limitations of the assessment and any risks involved. Consent Process: Patients (or parents/guardians for children under 16) must: Be given time to ask questions. Receive written information about the assessment process. Sign a written consent form before the assessment can proceed. Consent for Additional Testing: If further assessment (e.g., cognitive, behavioural) becomes necessary, separate consent must be obtained. Consent for Young People and Adults Lacking Capacity: Children under 16 may give consent if they are assessed as Gillick competent. If a patient lacks capacity to consent, decisions must be made in their best interests following the Mental Capacity Act 2005.Parents or legal guardians must provide consent for children unable to consent independently.

5.2 Documentation of Consent

Consent Form: All consent must be documented using the Dyslexia Assessment Consent Form. The consent form must include: Details of the assessment, Risks and benefits discussed, Information on data storage, access, and sharing, Date and signature of the patient (or parent/guardian if applicable)Clinician’s signature and date, Record-Keeping: Consent forms must be stored securely in the patient’s record. Records must be retained for 7 years (or until the patient’s 25th birthday for minors).

5.3 Data Protection and Confidentiality

Data Collection: Only information relevant to the dyslexia assessment will be collected. Data collected may include: Educational history, Medical and developmental history, Cognitive and literacy assessment results, Observations from parents, caregivers, or teachers, Data Security: All patient records will be stored securely in accordance with UK GDPR and ICO requirements. Paper records will be kept in locked storage accessible only to authorised staff. Digital records will be stored securely in password-protected systems with encryption. Information Sharing: Patient data will only be shared with: Educational institutions (e.g., schools, colleges) if consent is given. Other healthcare providers if clinically appropriate. External agencies (e.g., exam boards) for access arrangement purposes if consent is provided. Information will not be shared with third parties without explicit written consent unless required by law. Confidentiality Agreement: All staff involved in dyslexia assessments must sign a Confidentiality Agreement confirming their responsibility to protect sensitive information.

5.4 Patient Rights

Patients have the right to: Request access to their assessment records. Correct inaccurate or incomplete information in their records. Request the deletion of their records under UK GDPR where appropriate. Withdraw consent at any time.

5.5 Withdrawal of Consent

Process for Withdrawing Consent: Patients (or caregivers) can withdraw consent at any stage before or during the assessment. Withdrawal must be documented in the patient’s record. Assessment activities must cease immediately upon withdrawal. Data Management Following Withdrawal: If a patient withdraws consent for data storage, records will be securely deleted unless required by law to be retained.

6. Monitoring and Compliance

The Clinical Lead will monitor the consent process through quarterly audits of assessment records. The Governance Lead will monitor compliance with data protection standards. All data breaches will be reported in accordance with the Incident Reporting Policy.

7. Training and Awareness

All staff conducting dyslexia assessments must complete annual training on: Informed consent processes, Data protection and GDPR requirements, Confidentiality and safeguarding practices

8. Responsibilities

Clinical Lead: Ensure that informed consent is obtained and documented appropriately. Ensure that staff understand their obligations under this policy. Governance Lead: Ensure BrightPath Neuro's data protection procedures align with ICO guidance. Investigate and manage any reported data breaches. All Clinical Staff: Obtain and document consent in line with this policy. Ensure patient data is managed securely and shared only with authorised individuals.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Educational and Workplace Adjustments Policy

1. Purpose

This policy sets out the procedures and guidelines for identifying, recommending, and supporting educational and workplace adjustments for individuals with neurodevelopmental conditions, including dyslexia, autism spectrum condition (ASC), attention deficit hyperactivity disorder (ADHD), and other specific learning differences (SpLD).BrightPath Neuro recognises that individuals with neurodevelopmental conditions may experience barriers in education and work environments. Reasonable adjustments are essential to ensuring equal access to learning and employment opportunities, promoting inclusion, and supporting individuals to reach their full potential. The purpose of this policy is to: Establish a clear framework for recommending educational and workplace adjustments. Ensure that adjustments are tailored to individual needs and supported by clinical evidence. Ensure compliance with legal requirements for equality and accessibility. Promote a strengths-based approach to supporting individuals in education and work. Provide clear guidance to educational institutions and employers on implementing adjustments.

2. Scope

This policy applies to: All patients assessed and supported by BrightPath Neuro. All staff involved in recommending adjustments, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Educational Psychologists, Occupational Therapists, Speech and Language Therapists, Specialist Dyslexia Assessors, Administrative and Governance Staff, It covers: Adjustments for educational settings (schools, colleges, universities)Adjustments for workplace settings, Reasonable adjustments in line with legal requirements, Monitoring and reviewing adjustments

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that individuals with neurodevelopmental conditions have equal access to education and employment. Promoting a strengths-based approach to adjustments. Providing clear, evidence-based recommendations for adjustments. Ensuring that educational and workplace adjustments are reasonable, effective, and legally compliant. Working collaboratively with educational institutions and employers to implement adjustments.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Equality Act 2010 – Requires reasonable adjustments to prevent discrimination against individuals with disabilities, including neurodevelopmental conditions. Health and Safety at Work Act 1974 – Employers are required to ensure a safe and supportive work environment. Children and Families Act 2014 – Establishes the right to educational support for children with special educational needs (SEN).Special Educational Needs and Disability (SEND) Code of Practice 2015 – Outlines statutory guidance for supporting children and young people with SEN. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Data Protection Act 2018 (UK GDPR) – Establishes standards for processing and storing personal information. Joint Council for Qualifications (JCQ) Access Arrangements Guidance – Provides guidelines for exam access arrangements for students with disabilities.

5. Procedure

5.1 Identification of Need for Adjustments

Assessment and Diagnosis: Educational and workplace adjustments will be based on the outcomes of a formal assessment conducted at BrightPath Neuro. Adjustments may be recommended for individuals with: Dyslexia, Autism Spectrum Condition (ASC)ADHD, Dyspraxia (Developmental Coordination Disorder)Sensory Processing Disorder, Other specific learning difficulties (SpLD)Discussion with Patient and Caregiver: The assessing clinician must: Discuss the purpose and benefits of adjustments with the patient and/or caregiver. Explain how adjustments may affect educational or workplace performance. Discuss any potential limitations or barriers to implementing adjustments. Educational History: A detailed educational or workplace history should be gathered, including: Previous adjustments or support received, Academic or work performance, Environmental or social challenges, Functional impact of the neurodevelopmental condition, Occupational Health and Functional Assessment: For workplace adjustments, an occupational health assessment may be required to determine: Physical or cognitive challenges, Sensory or environmental barriers, Recommendations for assistive technology or work pattern adjustments

5.2 Types of Adjustments

At BrightPath Neuro, a range of educational and workplace adjustments may be implemented to support individuals with diverse needs. In educational settings, adjustments can include exam accommodations such as extra time, rest breaks, or the use of a scribe or reader. Classroom adjustments may involve providing quiet workspaces, headphones, or fidget tools. Learning materials can be adapted through large print, coloured overlays, or digital formats, while communication support might include sign language, speech-to-text software, or communication boards. Alternative teaching methods such as multi-sensory learning, visual aids, and simplified instructions help improve accessibility. Additional support may involve organisation and planning tools, like access to a learning mentor or organisational software, and social and emotional support through counselling or mental health services. In the workplace, adjustments may include flexible working arrangements, such as part-time hours, remote working, or staggered start times. Environmental modifications like quiet spaces, noise-cancelling headphones, or low lighting can improve comfort and focus. The use of assistive technology, including text-to-speech or speech recognition software, along with ergonomic equipment, can enhance productivity. Training and support for colleagues, such as neurodiversity awareness sessions and access to occupational health advisors, help foster an inclusive environment. Finally, role adjustments, including modifications to job responsibilities or the provision of additional training, ensure individuals can perform their roles effectively.

5.3 Implementing Adjustments

Educational Settings: Recommendations for educational adjustments must be: Provided in writing to the school, college, or university. Supported by evidence from the assessment report. Reviewed annually in line with the student’s progress. Exam Access Arrangements: Requests for exam access arrangements must: Follow JCQ guidelines. Include supporting evidence from the assessment report. Be submitted at least three months before the exam date. Workplace Settings: Recommendations for workplace adjustments must be: Provided in writing to the employer (with patient consent).Supported by an occupational health report (if applicable).Reviewed every 6 months or sooner if the patient’s condition changes. Patient Consent: Adjustments must not be implemented without written consent from the patient (or parent/guardian).

5.4 Monitoring and Review

Educational Adjustments: Adjustments must be reviewed annually or sooner if the patient’s condition changes. Review outcomes should be documented in the patient’s record. Workplace Adjustments: Adjustments should be reviewed every 6 months. If adjustments are ineffective, additional support or modifications should be considered. Patient Feedback: Patients should have the opportunity to provide feedback on the effectiveness of adjustments. If the patient is dissatisfied, alternative adjustments should be explored.

6. Monitoring and Compliance

The Clinical Lead will monitor the completion and implementation of adjustments. The Governance Lead will conduct quarterly audits of adjustment recommendations. Non-compliance with recommended adjustments will be addressed with the employer or educational institution directly.

7. Training and Awareness

All staff involved in recommending adjustments must complete annual training on: Reasonable adjustments under the Equality Act 2010JCQ and SEND guidelines for exam arrangements, Workplace diversity and inclusion strategies

8. Responsibilities

Clinical Lead: Ensure that adjustments are supported by clinical evidence. Monitor implementation of adjustments. Governance Lead: Monitor compliance with adjustment recommendations. All Clinical Staff: Provide clear recommendations for adjustments. Engage with educational and workplace staff to support adjustments.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Assessment Tools and Standards Policy (dyslexia)

1. Purpose

This policy sets out the procedures and guidelines for selecting and using assessment tools and maintaining clinical standards in the diagnosis and management of dyslexia at BrightPath Neuro. Dyslexia is a specific learning difficulty (SpLD) that primarily affects reading, spelling, and writing. Accurate and consistent assessment is essential for ensuring that individuals with dyslexia receive appropriate support and intervention. BrightPath Neuro is committed to using validated, evidence-based assessment tools that align with national and professional guidelines. The purpose of this policy is to: Ensure that dyslexia assessments are conducted using standardised, validated tools. Ensure that assessments are conducted consistently by qualified professionals. Ensure that findings from the assessment process are accurate, reliable, and reproducible. Maintain compliance with professional guidelines and regulatory standards. Provide clear guidance to clinicians on selecting, administering, and interpreting assessment tools.

2. Scope

This policy applies to: All patients referred for a dyslexia assessment at BrightPath Neuro. All staff involved in conducting and interpreting dyslexia assessments, including but not limited to: Educational Psychologists, Clinical Psychologists, Speech and Language Therapists, Specialist Dyslexia Assessors, Occupational Therapists, Administrative and Governance Staff, It covers: Selection of dyslexia assessment tools, Standardised administration and scoring of tests, Interpretation of assessment outcomes, Reporting and communication of findings, Monitoring and review of assessment standards

3. Policy Statement

BrightPath Neuro is committed to: Using evidence-based, validated assessment tools to diagnose dyslexia. Ensuring that dyslexia assessments are conducted consistently and reliably. Ensuring that staff conducting assessments are appropriately trained and qualified. Maintaining compliance with national and professional guidelines for dyslexia assessment. Ensuring that patients and caregivers understand the assessment process and outcomes.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Equality Act 2010 – Requires that reasonable adjustments are made for individuals with disabilities, including specific learning difficulties (SpLD).Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Care Quality Commission (CQC) Regulations, Special Educational Needs and Disability (SEND) Code of Practice 2015 – Establishes the legal framework for supporting students with SpLD. Joint Council for Qualifications (JCQ) Access Arrangements Guidance – Sets out guidelines for exam accommodations for students with SpLD. British Dyslexia Association (BDA) Guidelines, Health and Care Professions Council (HCPC) Standards of Proficiency, British Psychological Society (BPS) Guidelines, General Data Protection Regulation (UK GDPR) – Governs the collection, storage, and processing of assessment data.

5. Procedure

5.1 Selection of Assessment Tools

Criteria for Selecting Tools: Dyslexia assessment tools used at BrightPath Neuro must: Be evidence-based and validated for the intended age group. Be recognised by professional bodies such as the British Psychological Society (BPS) and British Dyslexia Association (BDA).Have established norms for the target population. Provide standardised administration and scoring procedures. Be culturally and linguistically appropriate for the patient. Review of Tools: The Clinical Lead will review the selection of tools annually to ensure they remain current and evidence-based. Tools will be updated if new evidence or professional guidelines are released. Approval of New Tools: New tools must be approved by the Clinical Governance Committee before implementation.

5.2 Dyslexia Assessment Tools

At BrightPath Neuro, dyslexia assessments are tailored to the individual needs of each patient, with the selection of tools based on factors such as age, presenting concerns, cognitive profile, and language abilities. A variety of validated and recognised tools may be used to gain a comprehensive understanding of the individual’s strengths and difficulties in areas such as reading, writing, and phonological processing. These may include the Wechsler Individual Achievement Test (WIAT-III) for assessing reading, spelling, and writing (ages 4–25), and the Comprehensive Test of Phonological Processing (CTOPP-2) for evaluating phonological skills (ages 4–24). Other tools may include the Wide Range Achievement Test (WRAT-5), Gray Oral Reading Test (GORT-5), and the Test of Word Reading Efficiency (TOWRE-2) for reading fluency and comprehension, alongside the Phonological Assessment Battery (PhAB) for younger individuals. Cognitive processing may be explored using the Woodcock-Johnson Tests of Cognitive Abilities, and the Dyslexia Screening Test (DST) may be used to provide a dyslexia risk profile. Clinicians will choose the most appropriate combination of tools based on the referral reason, ensuring a thorough and personalised assessment. Additional assessments may be incorporated if clinically indicated.

5.3 Standardisation of Administration and Scoring

Testing Conditions: Assessments must be conducted in a quiet, low-stimulation environment. All materials (e.g., test booklets, record forms) must be provided in line with the test publisher’s guidelines. The patient must be made comfortable and have adequate rest breaks if needed. Administration: Tests must be administered according to the guidelines set out by the test publisher. Any deviation from the standardised procedure must be recorded and justified. Scoring: Scores must be calculated using the scoring templates provided by the test publisher. Results must be interpreted using the established norms for the tool. Raw scores, standard scores, and percentile ranks must be documented. Combining Data: Results from multiple tools should be combined to develop a comprehensive profile of the patient’s strengths and weaknesses. Discrepancies between test results should be noted and explained in the assessment report.

5.4 Interpretation of Assessment Outcomes

Criteria for Diagnosing Dyslexia: A diagnosis of dyslexia may be made if the patient meets the following criteria: Significant discrepancy between intellectual ability and literacy performance. Persistent difficulty with phonological processing, decoding, and spelling. Deficits are not explained by other factors (e.g., sensory impairment, intellectual disability).Additional Considerations: Co-occurring difficulties (e.g., ADHD, dyspraxia) should be documented. Recommendations for educational or workplace adjustments should be made where appropriate.

5.5 Reporting and Communication

Assessment Report: A full diagnostic report must be completed within 14 working days of the final assessment. The report should include: Background information and presenting concerns, Results of each test, including scores and interpretations, Clinical observations, Diagnosis (if applicable)Recommendations for support and adjustments, Patient and Caregiver Feedback: The report should be shared with the patient and/or caregiver. The clinician should provide a verbal explanation of the results and recommendations.

5.6 Record Keeping and Confidentiality

Assessment records must be stored securely in line with UK GDPR and BrightPath’s Data Protection Policy. Records must be retained for 7 years (or until the patient’s 25th birthday for minors).

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of dyslexia assessments. Non-compliance with administration or scoring guidelines will result in corrective action.

7. Training and Awareness

All staff conducting dyslexia assessments must complete annual training on: Test administration and scoring, Interpretation of results, Report writing

8. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent and Prescribing for Dual Assessments (if medication is involved) Policy

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent and prescribing medication when conducting dual assessments for: Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Condition (ASC)ADHD and Dyslexia, Dual assessments require a structured and comprehensive approach to ensure that patients and caregivers understand the nature, purpose, and potential outcomes of the assessment and any associated treatments, including medication. Prescribing medication for ADHD or other related conditions following a dual assessment requires additional safeguards to ensure that patients and caregivers provide fully informed consent and understand the implications of medication use. The purpose of this policy is to: Ensure that informed consent is obtained before conducting a dual assessment. Ensure that patients and caregivers are fully informed about the benefits and risks of medication. Establish a clear framework for prescribing medication following a dual diagnosis. Ensure that prescribing practices follow national guidelines and professional standards. Ensure compliance with legal, ethical, and professional standards for informed consent and prescribing.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for a dual assessment involving: ADHD and Autism Spectrum Condition (ASC)ADHD and Dyslexia, All staff involved in the assessment, treatment, and prescribing process, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Educational Psychologists, Specialist Dyslexia Assessors, Occupational Therapists, Mental Health Nurses, Pharmacists, It covers: Consent for dual assessments, Consent for prescribing medication following a dual diagnosis, Risk and benefit discussion for medication and non-medication treatments, Documentation of consent and prescribing decisions, Monitoring and follow-up of prescribed medication

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that patients and caregivers are fully informed about the dual assessment and any associated medication. Providing a balanced overview of the benefits, risks, and side effects of medication. Respecting patient autonomy and the right to refuse medication. Following national and professional guidelines for prescribing medication. Monitoring and reviewing the impact of medication regularly to ensure safety and effectiveness.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of ADHD and ASC. British Dyslexia Association (BDA) Guidelines – Recommendations for the diagnosis and support of dyslexia. Joint Council for Qualifications (JCQ) Guidelines – Guidelines for exam accommodations for individuals with dyslexia. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Obtaining Informed Consent for Dual Assessments

Initial Discussion: Before conducting a dual assessment, the clinician must provide the patient and caregiver with a clear explanation of: The purpose and goals of the dual assessment. The nature of ADHD, ASC, and/or dyslexia and how they may interact. The assessment tools that will be used. The potential outcomes of the assessment. The possibility of a diagnosis or no diagnosis. The potential for treatment, including medication (if indicated).Risks and benefits of conducting a dual assessment. Any limitations of the assessment process. Consent Form: Patients (or caregivers for minors) must sign a written consent form before the assessment begins. The consent form must include: Description of the assessment process. Possible outcomes of the assessment. Information about data storage and confidentiality. Patient's right to refuse treatment or withdraw consent at any time. Capacity to Consent: If the patient is over 16, they are presumed to have the capacity to consent unless there is evidence to the contrary. If the patient is under 16, consent must be obtained from a parent or legal guardian unless the patient is assessed as Gillick competent. If the patient lacks capacity, decisions must be made in their best interests in line with the Mental Capacity Act 2005.

5.2 Consent for Prescribing Following a Dual Assessment

Discussion with Patient and Caregiver: Before prescribing medication, the clinician must explain: The name, type, and purpose of the medication. The expected benefits of the medication. The potential side effects and risks. Any alternative non-pharmacological treatments. The process for monitoring and reviewing medication. The potential for dependency or withdrawal symptoms (if applicable).The patient’s right to refuse medication or request alternative treatments. Written Consent: Written consent must be obtained before initiating medication. The consent form must include: Medication name and dosage. Expected benefits and risks. Possible side effects. Monitoring and review schedule. Signature of the patient (or caregiver if applicable).Risk-Benefit Assessment: The clinician must ensure that the potential benefits of medication outweigh the risks. If the patient refuses medication, alternative treatment options should be explored. If medication is not clinically indicated, the clinician should document this decision.

5.3 Documentation and Record-Keeping

Consent Records: All consent forms must be signed and dated. Copies of the consent form should be uploaded to the patient’s electronic health record. If consent is withdrawn, this should be documented clearly. Prescribing Records: All prescribed medication must be documented, including: Date prescribed, Dose and frequency, Duration of treatment, Reason for prescribing, Expected outcomes and monitoring plan

5.4 Monitoring and Review

Medication Monitoring: All medications prescribed for ADHD or other related conditions must be reviewed within 6 weeks of starting treatment. The following should be monitored: Effectiveness of the medication, Side effects and adverse reactions, Patient compliance and response, Adjustments to dosage or treatment should be made based on the patient’s response. Annual Review: An annual review should be conducted to assess the long-term effectiveness and safety of the medication. Alternative treatment options should be explored where necessary.

6. Monitoring and Compliance

The Clinical Lead will monitor completion of consent forms and prescribing records through quarterly audits. The Governance Lead will review prescribing decisions and monitor outcomes. All prescribing decisions must align with NICE guidelines and GMC professional standards.

7. Training and Awareness

All staff involved in prescribing medication must complete annual training on: ADHD and ASC prescribing guidelines, Monitoring and managing side effects, Shared decision-making and informed consent, Mental Capacity Act and safeguarding

8. Responsibilities

Clinical Lead: Ensure compliance with prescribing guidelines and consent procedures. Prescribing Clinician: Provide clear and balanced information about medication. Obtain and document informed consent. Governance Lead: Conduct audits of prescribing practices.

9. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (for dual assessments)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for dual conditions at BrightPath Neuro, specifically for: Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Condition (ASC)ADHD and Dyslexia, Diagnosing dual conditions requires a structured and evidence-based approach to ensure that both conditions are accurately identified and that the interaction between them is properly understood. The presence of co-occurring conditions can complicate the diagnostic process and treatment planning, making it essential to have a clear framework for conducting assessments. The purpose of this policy is to: Ensure that dual assessments are conducted using validated and evidence-based tools. Establish a clear framework for identifying overlapping symptoms and distinguishing between ADHD, ASC, and dyslexia. Ensure that assessment outcomes are communicated clearly to the patient and caregiver. Ensure that appropriate treatment and support plans are developed based on the assessment findings. Maintain compliance with professional standards and legal requirements for dual assessments.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for a dual assessment involving: ADHD and Autism Spectrum Condition (ASC)ADHD and Dyslexia, All staff involved in conducting dual assessments, including but not limited to: Medical Practitioners, Clinical Psychologists, Educational Psychologists, Non-Medical Prescribers (NMPs)Occupational Therapists, Speech and Language Therapists, Specialist Dyslexia Assessors, Mental Health Nurses, Administrative and Governance Staff, It covers: Referral and triage, Screening and pre-assessment process, Comprehensive diagnostic assessment, Communication of findings and recommendations, Development of a tailored treatment plan

3. Policy Statement

BrightPath Neuro is committed to: Providing a comprehensive, patient-centred approach to diagnosing dual conditions. Using validated and evidence-based assessment tools. Ensuring that patients and caregivers are actively involved in the assessment process. Providing clear and transparent information about the assessment process and outcomes. Delivering personalised recommendations and treatment plans. Ensuring compliance with professional and legal standards.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Equality Act 2010 – Ensures equal access to care and reasonable adjustments for individuals with disabilities. Special Educational Needs and Disability (SEND) Code of Practice 2015 – Establishes the framework for supporting students with learning difficulties. National Institute for Health and Care Excellence (NICE) Guidelines – Clinical guidelines for diagnosing and managing ADHD and ASC. British Dyslexia Association (BDA) Guidelines – Professional standards for dyslexia assessment and diagnosis. Joint Council for Qualifications (JCQ) Access Arrangements Guidance – Guidelines for exam accommodations. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and sharing of personal data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for dual assessments may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Self-referral (if aged 18 or older)Social care services, Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting concerns (e.g., academic, behavioural, emotional)Developmental and medical history, Previous educational assessments or support plans, Family history of neurodevelopmental or mental health conditions, Acceptance of Referral: The referral will be accepted if: Symptoms meet the initial criteria for ADHD and ASC or ADHD and dyslexia. Symptoms are not better explained by another medical or psychological condition. There is evidence of functional impairment in two or more settings (e.g., school, home, work).If the referral is not accepted, the referrer will be notified within 5 working days with an explanation and guidance on alternative support options.

5.2 Pre-Assessment Screening

At BrightPath Neuro, the pre-assessment screening process is designed to identify potential symptoms of ADHD, ASC, and dyslexia, rule out other medical or mental health conditions, and guide the appropriate selection of diagnostic tools and methods. A range of validated tools may be used depending on the individual’s age and presenting concerns. These include the Conners 4 Rating Scale (ages 6–18) for ADHD symptoms, the Autism Spectrum Quotient (AQ) (ages 4–18) for autistic traits, and the Strengths and Difficulties Questionnaire (SDQ) (ages 4–18) to screen for emotional and behavioural issues. The British Dyslexia Association Checklist (for ages 7 and up) is used to identify signs of dyslexia, while the Sensory Profile, applicable to all ages, helps assess sensory processing issues often associated with ASC. If screening suggests a high likelihood of co-occurring conditions, a full diagnostic assessment will be arranged. Where screening does not support a dual diagnosis, alternative explanations will be considered, and appropriate support options will be discussed.

5.3 Comprehensive Diagnostic Assessment

At BrightPath Neuro, the comprehensive diagnostic assessment process involves the use of validated tools and clinical expertise to identify conditions such as ADHD, ASC, and dyslexia. Key assessment tools may include the ADOS-2 for diagnosing autism spectrum conditions (ages 2–18), the Conners 4 or QbTest for assessing ADHD (ages 6–18), the Wechsler Individual Achievement Test (WIAT-III) to evaluate reading, spelling, and writing abilities (ages 4–25), and the Comprehensive Test of Phonological Processing (CTOPP-2) to assess phonological skills (ages 4–24). In addition to formal testing, clinicians will carry out direct clinical observation, analysing behaviours such as social communication, eye contact, and sensory responses. Information is also gathered from parents and teachers through standardised questionnaires and structured interviews, providing a comprehensive view of the individual’s functioning across different environments.

5.4 Communication of Results

Assessment Report: A full diagnostic report should be completed within 14 working days of the final assessment session. Summary of presenting concerns, Diagnostic findings, Strengths and weaknesses, Recommended adjustments and interventions, Treatment and medication options (if applicable)Patient and Caregiver Feedback: A face-to-face or virtual meeting will be held to explain the results. Written copies of the report will be provided to the patient and caregiver (if applicable).

5.5 Development of Treatment Plan

Treatment Recommendations: Personalised recommendations for educational or workplace adjustments. Medication options (if applicable).Psychological or occupational therapy support (if needed).Follow-Up: Follow-up appointments should be scheduled within 6 weeks of diagnosis.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and assessment outcomes. The Governance Lead will conduct quarterly audits of dual assessment processes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (for triad assessments)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for triad assessments at BrightPath Neuro, specifically for: Attention Deficit Hyperactivity Disorder (ADHD)Autism Spectrum Condition (ASC)Dyslexia, Triad assessments are complex due to the potential for co-occurrence and interaction between ADHD, ASC, and dyslexia. While these conditions share overlapping symptoms, it is also possible for an individual to meet the diagnostic criteria for all three conditions independently. Each condition has distinct diagnostic criteria, and the presence of one condition does not exclude the presence of the others. It is essential that the assessment process identifies both shared and unique symptoms, distinguishes between them, and accurately diagnoses the presence of all three conditions if clinically indicated. A structured, multi-disciplinary, and evidence-based approach is required to ensure an accurate diagnosis and an appropriate, tailored support plan. The purpose of this policy is to: Ensure that triad assessments are conducted using validated and evidence-based tools. Establish a clear framework for identifying and distinguishing between ADHD, ASC, and dyslexia. Ensure that patients are accurately diagnosed with one, two, or all three conditions where clinically indicated. Provide tailored treatment and support plans based on the assessment outcomes. Ensure compliance with professional and legal standards for triad assessments.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for a triad assessment involving ADHD, ASC, and dyslexia. All staff involved in conducting triad assessments, including but not limited to: Medical Practitioners, Clinical Psychologists, Educational Psychologists, Non-Medical Prescribers (NMPs)Occupational Therapists, Speech and Language Therapists, Specialist Dyslexia Assessors, Mental Health Nurses, Administrative and Governance Staff, It covers: Referral and triage, Screening and pre-assessment process, Comprehensive diagnostic assessment, Communication of findings and recommendations, Development of a tailored treatment plan

3. Policy Statement

BrightPath Neuro is committed to: Providing a comprehensive, patient-centred approach to diagnosing co-occurring ADHD, ASC, and dyslexia. Using validated and evidence-based assessment tools. Ensuring that patients and caregivers are actively involved in the assessment process. Providing clear and transparent information about the assessment process and outcomes. Delivering personalised recommendations and treatment plans. Ensuring compliance with professional and legal standards.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Equality Act 2010 – Ensures equal access to care and reasonable adjustments for individuals with disabilities. Special Educational Needs and Disability (SEND) Code of Practice 2015 – Establishes the framework for supporting students with learning difficulties. National Institute for Health and Care Excellence (NICE) Guidelines – Clinical guidelines for diagnosing and managing ADHD and ASC. British Dyslexia Association (BDA) Guidelines – Professional standards for dyslexia assessment and diagnosis. Joint Council for Qualifications (JCQ) Access Arrangements Guidance – Guidelines for exam accommodations. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and sharing of personal data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for triad assessments may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Self-referral (if aged 18 or older)Social care services, Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting concerns (e.g., academic, behavioural, emotional)Developmental and medical history, Previous educational assessments or support plans, Family history of neurodevelopmental or mental health conditions, Acceptance of Referral: The referral will be accepted if: Symptoms meet the initial criteria for ADHD, ASC, and/or dyslexia. Symptoms are not better explained by another medical or psychological condition. There is evidence of functional impairment in two or more settings (e.g., school, home, work).If the referral is not accepted, the referrer will be notified within 5 working days with an explanation and guidance on alternative support options.

5.2 Understanding the Interaction of ADHD, ASC, and Dyslexia

Co-occurrence vs. Overlap: While ADHD, ASC, and dyslexia share overlapping traits, it is also possible for a patient to meet the diagnostic criteria for all three conditions independently-occurrence means that the individual presents with symptoms and functional impairments consistent with more than one condition. Possible Patterns of Co-Occurrence: A patient with ADHD may also have ASC due to overlapping executive functioning and social communication issues. A patient with dyslexia and ADHD may struggle with attention and working memory, affecting reading and writing performance. A patient with ASC and dyslexia may have difficulties with language processing and social communication, alongside reading and spelling deficits. A patient with all three conditions may present with: Social communication difficulties (ASC)Attention and impulse control issues (ADHD)Language processing and literacy challenges (Dyslexia)Need for Multi-Disciplinary Input: Due to the complexity of triad diagnoses, input from multiple professionals is essential. Collaboration between psychologists, speech and language therapists, occupational therapists, and specialist dyslexia assessors is required to distinguish between overlapping and independent symptoms.

5.3 Pre-Assessment Screening

At BrightPath Neuro, the pre-assessment screening process plays a vital role in identifying symptoms of ADHD, autism spectrum conditions (ASC), and dyslexia, while also helping to rule out other medical or mental health concerns. This process informs the selection of appropriate diagnostic tools and methods tailored to each individual. A range of validated screening tools may be used depending on age and presentation. The Conners 4 Rating Scale (ages 6–18) screens for ADHD symptoms, the Autism Spectrum Quotient (AQ) (ages 4–18) assesses for autistic traits, and the Strengths and Difficulties Questionnaire (SDQ) (ages 4–18) evaluates emotional and behavioural difficulties. The British Dyslexia Association Checklist is used from age 7 and above to screen for dyslexia indicators, while the Sensory Profile, suitable for all ages, identifies sensory processing challenges. These tools collectively support accurate, informed, and holistic assessment planning.

5.4 Comprehensive Diagnostic Assessment

At BrightPath Neuro, the comprehensive diagnostic assessment is a structured process that combines standardised tools and clinical expertise to evaluate conditions such as ASC, ADHD, and dyslexia. Validated tools used may include the ADOS-2 for diagnosing autism spectrum conditions in individuals aged 2–18 years, and either the Conners 4 or QbTest for diagnosing ADHD in those aged 6–18 years. For literacy assessment, the Wechsler Individual Achievement Test (WIAT-III) is used to evaluate reading, spelling, and writing skills in individuals aged 4–25 years, while the Comprehensive Test of Phonological Processing (CTOPP-2) assesses phonological processing skills in individuals aged 4–24 years. In addition to these tools, clinical observation is a key component of the assessment, allowing clinicians to directly observe behaviours such as social communication, attention, and sensory responses during the assessment process.

5.5 Diagnosis and Treatment Plan

A patient may receive a diagnosis of one, two, or all three conditions. A comprehensive treatment plan should be tailored to the patient’s specific needs and diagnosis.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and assessment outcomes. The Governance Lead will conduct quarterly audits of triad assessment processes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Prescribing (triad) Policy (if medication is involved)

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent and prescribing medication when conducting triad assessments for: Attention Deficit Hyperactivity Disorder (ADHD)Autism Spectrum Condition (ASC)Dyslexia. It is possible for a patient to meet the diagnostic criteria for all three conditions independently. ADHD, ASC, and dyslexia share overlapping symptoms, but they are also distinct in their presentation, underlying mechanisms, and treatment requirements. While medication may be clinically indicated for ADHD, it is not a primary treatment for ASC or dyslexia. However, the presence of multiple diagnoses can influence the treatment approach and the expected response to medication. The purpose of this policy is to: Ensure that patients and caregivers are fully informed about the nature, purpose, and risks of medication in the context of a triad diagnosis. Ensure that prescribing decisions are evidence-based and tailored to the individual’s profile. Provide a clear framework for obtaining informed consent before prescribing medication. Ensure compliance with national guidelines and professional standards for prescribing. Establish a structured process for monitoring and reviewing prescribed medication.

2. Scope

This policy applies to: All patients diagnosed with ADHD, ASC, and/or dyslexia through a triad assessment at BrightPath Neuro. All staff involved in the prescribing process, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Educational Psychologists, Occupational Therapists, Speech and Language Therapists, Pharmacists, Mental Health Nurses, It covers: Consent for prescribing medication following a triad assessment, Risk-benefit analysis of medication use in cases of co-occurring conditions, Discussion of alternative treatment options, Documentation of consent and prescribing decisions, Monitoring and review of medication

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that prescribing decisions are clinically appropriate and supported by evidence. Respecting patient autonomy and the right to refuse medication. Providing patients and caregivers with balanced and accurate information about the benefits and risks of medication. Following national prescribing guidelines and professional standards. Ensuring that prescribing decisions are made in the best interests of the patient and tailored to their specific diagnosis and clinical needs.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of ADHD and ASC. British Dyslexia Association (BDA) Guidelines – Recommendations for the diagnosis and support of dyslexia. Joint Council for Qualifications (JCQ) Access Arrangements Guidance – Guidelines for exam accommodations. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Prescribing Considerations in a Triad Diagnosis

ADHD Medication: Medication may be prescribed for ADHD following a comprehensive assessment if: The patient meets the clinical criteria for ADHD. Symptoms of inattention, hyperactivity, and/or impulsivity cause significant functional impairment. Non-pharmacological interventions have been insufficient or inappropriate. First-line medications for ADHD include: Stimulants – Methylphenidate, lisdexamfetamine-stimulants – Atomoxetine, guanfacine, ASC and Dyslexia: There is no licensed medication for the core symptoms of ASC or dyslexia. However, medication for ADHD may help reduce associated difficulties, such as: Impulsivity and hyperactivity (ADHD)Emotional regulation difficulties (ASC)Executive functioning and attention deficits (Dyslexia)Pharmacological treatment for co-occurring anxiety or depression (if present) may also be considered. Risk-Benefit Analysis: IN cases of multiple diagnoses, the potential benefits of medication for ADHD must be weighed against: Potential adverse effects (e.g., increased anxiety or social withdrawal in ASC).Potential interaction with other prescribed medications. Impact on cognitive functioning, learning, and social skills. The possibility of masking symptoms of ASC or dyslexia.

5.2 Obtaining Informed Consent

Initial Discussion: Before prescribing medication, the clinician must provide the patient and caregiver with clear information about: The name, type, and purpose of the medication. The expected benefits of the medication. The potential side effects and risks. Any alternative non-pharmacological treatments. The process for monitoring and reviewing medication. The potential for dependency or withdrawal symptoms (if applicable).The right to refuse or withdraw from treatment. Written Consent: Written consent must be obtained before initiating medication. The consent form must include: Medication name and dosage. Expected benefits and risks. Possible side effects. Monitoring and review schedule. Signature of the patient (or caregiver if applicable).Capacity to Consent: If the patient is over 16, they are presumed to have the capacity to consent unless there is evidence to the contrary. If the patient is under 16, consent must be obtained from a parent or legal guardian unless the patient is assessed as Gillick competent. If the patient lacks capacity, decisions must be made in their best interests under the Mental Capacity Act.

5.3 Alternative and Non-Pharmacological Interventions

Educational and Behavioural Support: Individualised Education Plans (IEPs) for dyslexia, Behavioural therapy for ADHD, Social communication therapy for ASC, Occupational Therapy: Sensory integration therapy (ASC)Executive functioning and motor skills support (ADHD and dyslexia)Speech and Language Therapy: Language processing support (Dyslexia)Social communication (ASC)Psychological Support: Cognitive Behavioural Therapy (CBT) for emotional regulation and executive functioning. Anxiety and mood management.

5.4 Documentation and Record-Keeping

Consent Records: All consent forms must be signed and dated. Copies of the consent form should be uploaded to the patient’s electronic health record. If consent is withdrawn, this should be documented clearly. Prescribing Records: All prescribed medication must be documented, including: Date prescribed, Dose and frequency, Duration of treatment, Reason for prescribing, Expected outcomes and monitoring plan

5.5 Monitoring and Review

Medication Monitoring: All medications prescribed for ADHD must be reviewed within 6 weeks of starting treatment. The following should be monitored: Effectiveness of the medication, Side effects and adverse reactions, Patient compliance and response, Impact on ASC and dyslexia symptoms, Annual Review: An annual review should be conducted to assess the long-term effectiveness and safety of the medication. Alternative treatment options should be explored where necessary.

6. Monitoring and Compliance

The Clinical Lead will monitor completion of consent forms and prescribing records through quarterly audits. The Governance Lead will review prescribing decisions and monitor outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Assessment Tools and Standards Policy (triad)

1. Purpose

This policy sets out the procedures and guidelines for selecting and using assessment tools and maintaining clinical standards in the diagnosis and management of triad assessments at BrightPath Neuro, specifically for: Attention Deficit Hyperactivity Disorder (ADHD)Autism Spectrum Condition (ASC)Dyslexia, Triad assessments require a structured and multi-disciplinary approach because ADHD, ASC, and dyslexia can present with overlapping symptoms while also being distinct in their diagnostic profiles. The presence of one condition does not exclude the possibility of the others, and it is clinically possible for an individual to meet the diagnostic criteria for all three conditions. Accurate and consistent assessment is essential to ensure that the interaction between these conditions is understood, and that effective support and treatment plans are provided. BrightPath Neuro is committed to using validated, evidence-based assessment tools that align with national and professional guidelines. The purpose of this policy is to: Ensure that triad assessments are conducted using standardised, validated tools. Ensure that assessments are conducted consistently by qualified professionals. Ensure that findings from the assessment process are accurate, reliable, and reproducible. Maintain compliance with professional guidelines and regulatory standards. Provide clear guidance to clinicians on selecting, administering, and interpreting assessment tools.

2. Scope

This policy applies to: All patients referred for a triad assessment involving ADHD, ASC, and dyslexia at BrightPath Neuro. All staff involved in conducting and interpreting triad assessments, including but not limited to: Medical Practitioners, Clinical Psychologists, Educational Psychologists, Non-Medical Prescribers (NMPs)Occupational Therapists, Speech and Language Therapists, Specialist Dyslexia Assessors, Mental Health Nurses, Administrative and Governance Staff, It covers: Selection of triad assessment tools, Standardised administration and scoring of tests, Interpretation of assessment outcomes, Reporting and communication of findings, Monitoring and review of assessment standards

3. Policy Statement

BrightPath Neuro is committed to: Using evidence-based, validated assessment tools to diagnose ADHD, ASC, and dyslexia. Ensuring that triad assessments are conducted consistently and reliably. Ensuring that staff conducting assessments are appropriately trained and qualified. Maintaining compliance with national and professional guidelines for triad assessments. Ensuring that patients and caregivers understand the assessment process and outcomes.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Equality Act 2010 – Requires that reasonable adjustments are made for individuals with disabilities, including specific learning difficulties (SpLD).Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, Special Educational Needs and Disability (SEND) Code of Practice 2015 – Establishes the legal framework for supporting students with SpLD. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of ADHD and ASC. British Dyslexia Association (BDA) Guidelines – Recommendations for the diagnosis and support of dyslexia. Joint Council for Qualifications (JCQ) Access Arrangements Guidance – Provides guidelines for exam accommodations. General Data Protection Regulation (UK GDPR) – Governs the collection, storage, and processing of assessment data. British Psychological Society (BPS) Guidelines – Standards for psychological and educational assessments.

5. Procedure

5.1 Selection of Assessment Tools

Criteria for Selecting Tools: Triad assessment tools used at BrightPath Neuro must: Be evidence-based and validated for the intended age group. Be recognised by professional bodies such as the British Psychological Society (BPS) and British Dyslexia Association (BDA).Have established norms for the target population. Provide standardised administration and scoring procedures. Be culturally and linguistically appropriate for the patient. Be suitable for identifying and distinguishing between ADHD, ASC, and dyslexia. Review of Tools: The Clinical Lead will review the selection of tools annually to ensure they remain current and evidence-based. Tools will be updated if new evidence or professional guidelines are released. Approval of New Tools: New tools must be approved by the Clinical Governance Committee before implementation.

5.2 Core Assessment Tools for Triad Diagnosis

At BrightPath Neuro, the tools used for triad assessment—covering autism spectrum condition (ASC), ADHD, and dyslexia—are carefully selected based on the individual needs of each patient. Factors influencing tool selection include the patient’s age, presenting concerns, cognitive profile, and language abilities. A range of validated and widely recognised tools may be employed. For ASC, the ADOS-2 (ages 2–18) provides structured observational assessment, while the Autism Spectrum Quotient (AQ) (ages 4–18) screens for autistic traits, and the Sensory Profile assesses sensory processing challenges across all age groups. ADHD assessment may involve the Conners 4 Rating Scale (ages 6–18), the QbTest (ages 6–60) for measuring attention, impulsivity, and hyperactivity, and the Strengths and Difficulties Questionnaire (SDQ) (ages 4–18) to explore emotional and behavioural difficulties. For dyslexia, the Wechsler Individual Achievement Test (WIAT-III) (ages 4–25) evaluates reading, spelling, and writing, while the Comprehensive Test of Phonological Processing (CTOPP-2) (ages 4–24) examines phonological processing skills. Clinicians will determine the most appropriate combination of tools based on the referral reason and the individual’s profile, with additional assessments used if clinically indicated.

5.3 Standardisation of Administration and Scoring

Testing Conditions: Assessments must be conducted in a quiet, low-stimulation environment. All materials (e.g., test booklets, record forms) must be provided in line with the test publisher’s guidelines. The patient must be made comfortable and have adequate rest breaks if needed. Administration: Tests must be administered according to the guidelines set out by the test publisher. Any deviation from the standardised procedure must be recorded and justified. Scoring: Scores must be calculated using the scoring templates provided by the test publisher. Results must be interpreted using the established norms for the tool. Raw scores, standard scores, and percentile ranks must be documented. Combining Data: Results from multiple tools should be combined to develop a comprehensive profile of the patient’s strengths and weaknesses. Discrepancies between test results should be noted and explained in the assessment report.

5.4 Interpretation of Assessment Outcomes

Diagnostic Criteria: A diagnosis of ADHD, ASC, and/or dyslexia may be made if the patient meets the formal diagnostic criteria for each condition. Overlapping symptoms should be carefully distinguished using clinical judgement and a multi-disciplinary approach. Co-Occurring Conditions: If the patient meets the criteria for two or more conditions, a combined diagnosis should be made, and the interaction between symptoms should be explained in the report.

5.5 Reporting and Communication

Assessment Report: A full diagnostic report must be completed within 14 working days of the final assessment. The report should include: Background information and presenting concerns, Results of each test, including scores and interpretations, Clinical observations, Diagnosis (if applicable)Recommendations for support and adjustments

6. Monitoring and Compliance

The Clinical Lead will conduct quarterly audits of triad assessments. Non-compliance with administration or scoring guidelines will result in corrective action.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (sleep assessment)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for sleep-related difficulties at BrightPath Neuro. Sleep is a fundamental aspect of physical and mental health. Sleep disturbances are common in individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. Poor sleep quality can significantly impact mood regulation, cognitive functioning, behaviour, learning, and overall well-being. The purpose of this policy is to: Provide a structured and consistent approach to the assessment and screening of sleep-related difficulties. Ensure that sleep assessments are conducted using validated and evidence-based tools. Identify the underlying causes and factors contributing to sleep difficulties. Develop tailored intervention plans to improve sleep quality and overall functioning. Ensure that assessment outcomes are communicated clearly to the patient and caregiver. Ensure compliance with national guidelines and professional standards for sleep assessments.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for a sleep assessment. All staff involved in conducting sleep assessments, including but not limited to: Medical Practitioners, Clinical Psychologists, Occupational Therapists, Speech and Language Therapists, Non-Medical Prescribers (NMPs)Mental Health Nurses, Administrative and Governance Staff, It covers: Referral and triage, Screening and pre-assessment process, Comprehensive sleep assessment, Communication of findings and recommendations, Development of a tailored treatment plan

3. Policy Statement

BrightPath Neuro is committed to: Providing a comprehensive, patient-centred approach to sleep assessments. Using validated and evidence-based assessment tools. Ensuring that patients and caregivers are actively involved in the assessment process. Providing clear and transparent information about the assessment process and outcomes. Delivering personalised recommendations and treatment plans. Ensuring compliance with professional and legal standards.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and management of sleep disorders. Equality Act 2010 – Ensures equal access to care and reasonable adjustments for individuals with disabilities. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and sharing of personal data. British Psychological Society (BPS) Guidelines – Standards for psychological and sleep-related assessments. British Sleep Society Guidelines – Best practice recommendations for sleep assessments.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for sleep assessments may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Self-referral (if aged 18 or older)Social care services, Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting sleep-related concerns (e.g., difficulty falling asleep, night waking, nightmares)Co-occurring mental health or neurodevelopmental conditions (e.g., ADHD, ASC, anxiety)Previous sleep assessments or treatment, Family history of sleep disorders, Medication and substance use history, Acceptance of Referral: The referral will be accepted if: Symptoms meet the initial criteria for sleep-related difficulties. There is evidence of functional impairment (e.g., poor school or work performance, emotional regulation issues).Sleep difficulties are not better explained by another medical or psychological condition. If the referral is not accepted, the referrer will be notified within 5 working days with an explanation and guidance on alternative support options.

5.2 Pre-Assessment Screening

At BrightPath Neuro, the pre-assessment screening process for sleep-related difficulties is designed to identify symptoms, rule out other medical or mental health conditions, and guide the appropriate selection of diagnostic tools. A range of validated tools may be used depending on the patient’s age and presenting concerns. These include the Children's Sleep Habits Questionnaire (CSHQ) for ages 4–18, the Pittsburgh Sleep Quality Index (PSQI) for individuals aged 18 and above, and the Epworth Sleepiness Scale (ESS), which assesses daytime sleepiness in those aged 12 and above. The Sleep Disturbance Scale for Children (SDSC) is used for children aged 6–16 to measure the severity of sleep disturbances. In addition, actigraphy, a wearable device that tracks sleep patterns, and a sleep diary may be used across all age groups to gather detailed information on sleep duration, quality, and routine. If significant sleep-related issues are identified, a full sleep assessment will be arranged. If not, other potential explanations will be considered, and suitable support options will be explored.

5.3 Comprehensive Sleep Assessment

Components of a Sleep Assessment: A full sleep assessment should include: Detailed sleep history – Bedtime routines, night waking's, sleep duration, sleep latency, daytime functioning. Medical and developmental history – Including medications and co-occurring conditions. Family and environmental factors – Family sleep patterns, noise, light, and temperature. Behavioural and emotional factors – Anxiety, stress, trauma, sensory sensitivities. Sleep hygiene and routines – Regularity of bedtime, screen use, and pre-sleep behaviours. Clinical Observation: Direct observation of the patient’s behaviour during the assessment process. Analysis of physical and emotional cues related to sleep quality. Parent and Caregiver Input: Parents or caregivers should be involved in the assessment process, particularly for younger children. Structured interviews with parents should explore: Family sleep routines, Parental approaches to managing sleep difficulties

5.4 Diagnosis and Communication of Results

Diagnostic Criteria: A diagnosis of a sleep-related disorder may be made if the patient meets the criteria for: Insomnia – Difficulty falling or staying asleep despite adequate opportunity for sleep. Delayed Sleep Phase Disorder (DSPD) – Difficulty initiating sleep and waking at a conventional time. Restless Legs Syndrome (RLS) – Sensory discomfort and an urge to move the legs at night. Obstructive Sleep Apnea (OSA) – Disrupted breathing during sleep due to airway obstruction. Assessment Report: A full diagnostic report should be completed within 14 working days of the final assessment session. Summary of presenting concerns, Diagnostic findings, Strengths and weaknesses, Recommended adjustments and interventions, Medication options (if applicable)Patient and Caregiver Feedback: A face-to-face or virtual meeting will be held to explain the results. Written copies of the report will be provided to the patient and caregiver (if applicable).

5.5 Development of Treatment Plan

Treatment Recommendations: Cognitive Behavioural Therapy for Insomnia (CBT-I)Sleep hygiene adjustments, Environmental modifications, Pharmacological options (if indicated)Follow-Up: Follow-up appointments should be scheduled within 6 weeks of diagnosis.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and assessment outcomes. The Governance Lead will conduct quarterly audits of sleep assessments.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Prescribing (sleep) Policy (if medication is involved)

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent and prescribing medication when treating sleep-related difficulties at BrightPath Neuro. Sleep disturbances are common in individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. Medication may be considered where non-pharmacological interventions (e.g., sleep hygiene, cognitive behavioural therapy for insomnia) have been ineffective or where the severity of sleep disruption is causing significant functional impairment. The purpose of this policy is to: Ensure that patients and caregivers are fully informed about the nature, purpose, and risks of medication for sleep-related difficulties. Ensure that prescribing decisions are evidence-based and tailored to the individual’s needs and diagnosis. Provide a clear framework for obtaining informed consent before prescribing medication. Ensure compliance with national guidelines and professional standards for prescribing. Establish a structured process for monitoring and reviewing prescribed medication.

2. Scope

This policy applies to: All patients at BrightPath Neuro who are being treated for sleep-related difficulties. All staff involved in prescribing medication for sleep-related difficulties, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Pharmacists, Mental Health Nurses, It covers: Consent for prescribing medication following a sleep assessment, Risk-benefit analysis of medication use for sleep-related difficulties, Discussion of alternative treatment options, Documentation of consent and prescribing decisions, Monitoring and review of medication

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that prescribing decisions are clinically appropriate and supported by evidence. Respecting patient autonomy and the right to refuse medication. Providing patients and caregivers with balanced and accurate information about the benefits and risks of medication. Following national prescribing guidelines and professional standards. Ensuring that prescribing decisions are made in the best interests of the patient and tailored to their specific diagnosis and clinical needs.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of sleep disorders. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data. British Sleep Society Guidelines – Best practice recommendations for sleep assessments and treatment.

5. Procedure

5.1 Prescribing Considerations for Sleep-Related Medication

Non-Pharmacological First-Line Approach: Non-medication strategies should be attempted before medication is considered. First-line approaches include: Sleep hygiene adjustments (e.g., reducing screen time, bedtime routines)Cognitive Behavioural Therapy for Insomnia (CBT-I)Environmental modifications (e.g., noise reduction, blackout blinds)Sensory adjustments (e.g., weighted blankets, white noise)When to Consider Medication: Medication may be considered if: Sleep difficulties persist despite non-pharmacological interventions. Sleep disruption is causing significant functional impairment (e.g., impact on mental health, school/work performance).Co-occurring conditions (e.g., ADHD, ASC, anxiety) are exacerbating sleep difficulties. The patient experiences physical health complications (e.g., exhaustion, poor immune function). At BrightPath Neuro, various medications may be considered to support individuals experiencing sleep disturbances, depending on the nature and underlying causes of the issue. Melatonin is commonly used to regulate the sleep–wake cycle and is particularly helpful for sleep onset difficulties and delayed sleep phase syndrome. Clonidine may be prescribed for ADHD-related sleep difficulties, as it helps reduce hyperarousal and supports sleep initiation. Promethazine, a sedating antihistamine, may be used on a short-term basis to assist with sleep onset. For individuals experiencing sleep maintenance difficulties or insomnia linked with anxiety or depression, Trazodone may be effective in low doses. Similarly, Mirtazapine, an antidepressant with sedative properties, may be considered where sleep maintenance issues are accompanied by anxiety. Medication choice is always tailored to the individual's needs and used alongside behavioural and environmental strategies where appropriate.

5.2 Obtaining Informed Consent

Initial Discussion: Before prescribing medication, the clinician must provide the patient and caregiver with clear information about: The name, type, and purpose of the medication. The expected benefits of the medication. The potential side effects and risks (e.g., drowsiness, dependency).Any potential interactions with other medications. Any alternative non-pharmacological treatments. The process for monitoring and reviewing medication. The potential for dependency or withdrawal symptoms (if applicable).The right to refuse or withdraw from treatment. Written Consent: Written consent must be obtained before initiating medication. The consent form must include: Medication name and dosage. Expected benefits and risks. Possible side effects. Monitoring and review schedule. Signature of the patient (or caregiver if applicable).Capacity to Consent: If the patient is over 16, they are presumed to have the capacity to consent unless there is evidence to the contrary. If the patient is under 16, consent must be obtained from a parent or legal guardian unless the patient is assessed as Gillick competent. If the patient lacks capacity, decisions must be made in their best interests under the Mental Capacity Act.

5.3 Alternative and Non-Pharmacological Interventions

Sleep Hygiene Adjustments: Regular sleep schedule, Avoiding stimulants before bedtime (e.g., caffeine, blue light)Relaxation techniques (e.g., deep breathing, mindfulness)Cognitive Behavioural Therapy for Insomnia (CBT-I):Restructuring negative thoughts about sleep, Improving bedtime routines, Increasing sleep efficiency, Environmental and Sensory Adjustments: Blackout curtains, Weighted blankets, White noise machines, Psychological and Emotional Support: Managing underlying anxiety or depression, Providing coping strategies for stress

5.4 Documentation and Record-Keeping

Consent Records: All consent forms must be signed and dated. Copies of the consent form should be uploaded to the patient’s electronic health record. If consent is withdrawn, this should be documented clearly. Prescribing Records: All prescribed medication must be documented, including: Date prescribed, Dose and frequency, Duration of treatment, Reason for prescribing, Expected outcomes and monitoring plan

5.5 Monitoring and Review

Medication Monitoring: All medications prescribed for sleep must be reviewed within 4–6 weeks of starting treatment. The following should be monitored: Effectiveness of the medication, Side effects and adverse reactions, Patient compliance and response, Impact on co-occurring conditions (e.g., ADHD, anxiety)Annual Review: An annual review should be conducted to assess the long-term effectiveness and safety of the medication. Alternative treatment options should be explored where necessary.

6. Monitoring and Compliance

The Clinical Lead will monitor completion of consent forms and prescribing records through quarterly audits. The Governance Lead will review prescribing decisions and monitor outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Medication and Treatment Plan Policy (for sleep)

1. Purpose

This policy sets out the procedures and guidelines for developing and managing medication and treatment plans for patients with sleep-related difficulties at BrightPath Neuro. Sleep disturbances are common in individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. Poor sleep quality can significantly affect mood, emotional regulation, cognitive performance, behaviour, and overall mental health. At BrightPath Neuro, the approach to treating sleep difficulties is based on a combination of non-pharmacological and pharmacological interventions. Medication should only be prescribed when clinically indicated and after non-pharmacological strategies have been attempted or deemed unsuitable. The purpose of this policy is to: Ensure that medication and treatment plans for sleep-related difficulties are evidence-based and patient-centred. Provide a structured framework for developing, implementing, and reviewing treatment plans. Ensure that medications for sleep are prescribed and monitored safely and effectively. Ensure that patients and caregivers are actively involved in the treatment planning process. Establish a consistent process for monitoring treatment outcomes and adjusting plans as necessary.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for sleep-related difficulties. All staff involved in the development and management of sleep-related treatment plans, including but not limited to: Medical Practitioners, Clinical Psychologists, Educational Psychologists, Non-Medical Prescribers (NMPs)Occupational Therapists Speech and Language Therapists, Pharmacists, Mental Health Nurses, It covers: Development of a comprehensive treatment plan for sleep difficulties, Use of both non-pharmacological and pharmacological interventions, Patient and caregiver involvement in the treatment planning process, Monitoring and adjusting treatment plans based on patient response, Ensuring compliance with professional standards and guidelines

3. Policy Statement

BrightPath Neuro is committed to: Providing a comprehensive, multi-disciplinary approach to managing sleep difficulties. Ensuring that treatment plans are evidence-based, patient-centred, and clinically appropriate. Offering non-pharmacological interventions as the first-line approach wherever possible. Prescribing medication only when clinically indicated and following professional guidelines. Monitoring treatment outcomes regularly and adjusting the plan as needed. Ensuring that patients and caregivers are fully informed and involved in decision-making.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of sleep disorders. British Sleep Society Guidelines – Best practice recommendations for sleep assessments and treatment. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Development of a Comprehensive Treatment Plan

Initial Assessment: A full sleep assessment must be conducted before initiating a treatment plan. The assessment should include: Sleep history (e.g., duration, quality, sleep-wake cycle)Medical history and current medications, Co-occurring neurodevelopmental or mental health conditions, Behavioural and environmental factors (e.g., bedroom environment, bedtime routine)Patient’s perception of sleep quality and functional impact, Shared Decision-Making: The patient (or caregiver) must be actively involved in developing the treatment plan. The clinician should discuss: Available treatment options, Expected benefits and risks of each option, The patient’s preferences and goals, The need for flexibility and review of the plan over time, Treatment Plan Components: The treatment plan should include: Non-Pharmacological Interventions – First-line treatments to improve sleep hygiene and behaviour. Pharmacological Interventions – Only if clinically indicated. Environmental Adjustments – Modifications to the sleep environment to promote sleep. Monitoring and Review Schedule – Regular reviews to evaluate treatment effectiveness and adjust as needed.

5.2 Non-Pharmacological Interventions

Sleep Hygiene Adjustments: Establishing a regular sleep-wake schedule, Avoiding stimulants before bedtime (e.g., caffeine, screens)Creating a relaxing bedtime routine, Maintaining a comfortable sleep environment (e.g., blackout curtains, quiet room)Behavioural and Psychological Interventions: Cognitive Behavioural Therapy for Insomnia (CBT-I) – To address negative thoughts about sleep and improve sleep behaviour. Relaxation Techniques – Deep breathing, mindfulness, or guided imagery. Stimulus Control Therapy – Encouraging the patient to associate the bed only with sleep. Environmental Adjustments: Adjusting room temperature, noise, and lighting, Using weighted blankets or white noise machines, Removing distractions from the bedroom environment

5.3 Pharmacological Interventions

At BrightPath Neuro, pharmacological interventions for sleep difficulties are only considered when non-pharmacological strategies have proven insufficient, the sleep issues are causing significant functional impairment, and the benefits of medication outweigh the potential risks. A range of medications may be used depending on the specific sleep concern. Melatonin is commonly prescribed to regulate the sleep–wake cycle, particularly for sleep onset difficulties, and may be used either short-term or long-term. Clonidine, helpful in managing ADHD-related sleep disturbances, can also be prescribed for both short- and long-term use. Promethazine, a sedating antihistamine, is typically reserved for short-term use in addressing sleep onset issues. For sleep maintenance difficulties, Trazodone, a low-dose antidepressant, may be used short- or long-term, while Mirtazapine, also with sedative properties, is often prescribed long-term, especially when anxiety is also present. Prescribing should always begin with the lowest effective dose, with ongoing monitoring for side effects and adverse reactions. Doses should be adjusted based on the individual’s response and tolerance, ensuring that medication is not masking underlying conditions such as anxiety or depression.

5.4 Monitoring and Review

Regular Monitoring: All sleep medications must be reviewed within 4–6 weeks of initiation. The review should assess: Effectiveness of the medication, Side effects or adverse reactions, Impact on sleep duration and quality, Functional improvements in daytime behaviour, Ongoing Review: Regular follow-ups should occur at least every 3 months while on medication. Consider tapering off medication if sleep patterns improve. Adjust the treatment plan as needed based on patient response. Annual Review: A full review of the treatment plan should be conducted annually. Alternative treatment options should be explored if progress is limited.

5.5 Documentation and Record-Keeping

Treatment Records: All treatment plans must be documented in the patient’s electronic health record. Details should include: Medication (if prescribed)Non-pharmacological strategies, Monitoring and review schedule, Patient feedback and outcomes, Consent Records: All consent forms must be completed and signed before initiating medication. Changes to the treatment plan should be documented and signed by the patient (or caregiver).

6. Monitoring and Compliance

The Clinical Lead will monitor treatment outcomes and adherence to this policy through quarterly audits. The Governance Lead will review prescribing decisions and patient outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

CBT for Insomnia (CBT-I) Policy

1. Purpose

This policy sets out the procedures and guidelines for the delivery of Cognitive Behavioural Therapy for Insomnia (CBT-I) at BrightPath Neuro. Insomnia is a common issue among individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. Poor sleep quality and sleep disruption can significantly impact mood regulation, cognitive function, behaviour, and overall quality of life. CBT-I is an evidence-based, first-line psychological intervention for chronic insomnia. It targets the underlying thoughts, behaviours, and environmental factors that contribute to sleep difficulties. CBT-I is recognised by the National Institute for Health and Care Excellence (NICE) as the most effective non-pharmacological treatment for insomnia, with long-term benefits extending beyond symptom reduction. The purpose of this policy is to: Ensure that CBT-I is delivered consistently and effectively at BrightPath Neuro. Provide a clear framework for assessing, planning, delivering, and reviewing CBT-I treatment. Ensure that CBT-I interventions are tailored to the individual's sleep difficulties and co-occurring conditions. Ensure that patients and caregivers are actively involved in the treatment process. Monitor and evaluate the effectiveness of CBT-I interventions.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for sleep-related difficulties. All staff involved in the delivery of CBT-I, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Occupational Therapists, Mental Health Nurses, Medical Practitioners, Non-Medical Prescribers (NMPs)It covers: Assessment and suitability for CBT-I, Delivery of CBT-I sessions, Modification of CBT-I for individuals with neurodevelopmental conditions, Monitoring and reviewing treatment outcomes

3. Policy Statement

BrightPath Neuro is committed to: Delivering CBT-I in line with professional guidelines and best practice. Ensuring that CBT-I interventions are patient-centred and evidence-based. Providing adjustments to CBT-I delivery to meet the individual needs of neurodivergent patients. Monitoring the effectiveness of CBT-I and adjusting treatment where necessary. Ensuring that patients and caregivers are fully informed and supported throughout the treatment process.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of insomnia. British Sleep Society Guidelines – Best practice recommendations for sleep assessments and treatments. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Assessment and Suitability for CBT-I

Referral and Screening: Referrals for CBT-I may come from: General Practitioners (GP)Schools or SENCOs, Mental health services (e.g., CAMHS)Self-referral (if aged 18 or older)Patients will be screened using: Pittsburgh Sleep Quality Index (PSQI) – Assesses overall sleep quality, Epworth Sleepiness Scale (ESS) – Assesses levels of daytime sleepiness, Sleep Diary – To track sleep patterns over 1–2 weeks, Clinical Criteria for CBT-I:A patient may be offered CBT-I if they meet the following criteria: Symptoms of chronic insomnia lasting 3 months or longer. Sleep difficulties cause significant functional impairment in daily life. Non-pharmacological treatments (e.g., sleep hygiene) have been ineffective. No evidence of a primary sleep disorder that requires medical intervention (e.g., obstructive sleep apnea). Co-Occurring Conditions: CBT-I can be modified for patients with: ADHD – Adjust for attention deficits and hyperactivity. ASC – Modify sensory and environmental factors. Dyslexia – Provide written materials in accessible formats. Anxiety and Depression – Adjust content to target underlying emotional dysregulation.

5.2 Structure of CBT-I

CBT-I at BrightPath Neuro will follow a 6–8 session structure, delivered either weekly or fortnightly. Each session should last 45–60 minutes. Session 1 – Psychoeducation and Sleep Diary Review: Explain the sleep-wake cycle and the factors that influence sleep. Review the patient's sleep diary. Provide an overview of CBT-I techniques and expected outcomes. Session 2 – Sleep Restriction Therapy (SRT):Restrict the time spent in bed to the average total sleep time recorded in the sleep diary. Gradually increase sleep time as sleep efficiency improves. Session 3 – Stimulus Control Therapy: Encourage the patient to associate the bed only with sleep. Establish a consistent bedtime and wake-up time. Encourage the patient to leave the bed if unable to sleep within 20 minutes. Session 4 – Cognitive Restructuring: Identify and challenge negative thoughts about sleep. Replace unhelpful beliefs with realistic, evidence-based thinking. Provide coping strategies for nighttime anxiety or frustration. Session 5 – Relaxation and Arousal Reduction: Teach relaxation techniques (e.g., deep breathing, progressive muscle relaxation).Address hyperarousal and physiological tension at bedtime. Session 6 – Sleep Hygiene and Maintenance: Reinforce sleep hygiene practices. Address environmental factors that may impact sleep. Develop a long-term maintenance plan. Session 7–8 – Relapse Prevention and Monitoring: Discuss challenges and strategies for managing setbacks. Provide guidance on when to seek additional support. Finalise the sleep management plan.

5.3 Adjustments for Neurodivergent Patients

ADHD: Shorter sessions may be needed due to attention difficulties. Provide written and visual prompts. Offer movement breaks if needed. ASC: Minimise sensory input (e.g., lighting, noise).Use concrete language and visual schedules. Adjust expectations for sleep patterns based on sensory processing differences. Dyslexia: Provide audio recordings or large print materials. Use visual aids and structured content. Minimise reliance on reading-based tasks.

5.4 Documentation and Record-Keeping

Session Records: All CBT-I sessions must be documented, including: Date and duration of session. Topics covered and techniques applied. Patient's response and progress. Any issues raised or concerns noted. Outcome Records: Sleep improvement should be tracked using: PSQI or sleep diary scores, Patient-reported sleep quality and daytime functioning, Reduction in night-time waking's and sleep latency, Consent Records: A signed consent form must be obtained before starting CBT-I. Any modifications to the treatment plan should be documented and signed by the patient (or caregiver).

5.5 Monitoring and Review

Follow-Up: A follow-up appointment should be scheduled 4–6 weeks after completing CBT-I. If sleep difficulties persist, alternative treatments should be considered. Annual Review: An annual audit of CBT-I delivery and outcomes should be conducted. Adjustments to the CBT-I protocol should be made based on outcome data and patient feedback.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and treatment outcomes. The Governance Lead will conduct quarterly audits of CBT-I delivery and outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (weight management)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for weight management at BrightPath Neuro. Weight-related issues, including overweight, obesity, and underweight, are common in individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. Medication used for treating ADHD, such as stimulants, can contribute to appetite suppression and weight loss. Conversely, some medications used for sleep, mood regulation, and emotional regulation (e.g., antipsychotics, antidepressants) can lead to weight gain and metabolic issues. Weight management is essential for improving overall health, emotional well-being, and cognitive performance. Identifying and managing weight-related issues early can prevent long-term health complications, such as cardiovascular disease, diabetes, and poor mental health. The purpose of this policy is to: Provide a structured and evidence-based approach to assessing and managing weight-related issues. Ensure that all weight assessments are conducted using validated tools and methods. Identify the underlying factors contributing to weight gain or loss. Develop tailored, person-centred weight management plans. Provide appropriate referrals and interventions where necessary. Ensure compliance with professional standards and guidelines.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for weight-related concerns. All staff involved in conducting and managing weight assessments, including but not limited to: Medical Practitioners, Clinical Psychologists, Non-Medical Prescribers (NMPs)Occupational Therapists, Dietitians and Nutritionists, Mental Health Nurses, Pharmacists, It covers: Referral and triage for weight management assessments, Screening and initial assessment process, Identification of underlying causes of weight issues, Development of an Individualised weight management plan, Monitoring and review of treatment outcomes

3. Policy Statement

BrightPath Neuro is committed to: Providing a comprehensive, patient-centred approach to weight management. Ensuring that weight management assessments are conducted using validated and evidence-based tools. Addressing the psychological, behavioural, and medical factors that contribute to weight issues. Providing tailored advice and support based on individual patient needs. Ensuring that patients and caregivers are actively involved in the assessment and treatment process. Monitoring and reviewing weight management outcomes regularly.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Guidelines on weight management, obesity, and healthy eating. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Equality Act 2010 – Ensures equal access to care and reasonable adjustments for individuals with disabilities. British Dietetic Association (BDA) Guidelines – Professional standards for dietary advice and support. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for weight management may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Current weight and height, Recent weight changes, Co-occurring health conditions (e.g., diabetes, metabolic syndrome)Current medication and known side effects, Eating habits and patterns, Physical activity levels, Psychological factors (e.g., body image concerns, emotional eating)Acceptance of Referral: The referral will be accepted if: The patient meets the criteria for weight-related issues (BMI below 18.5 or above 25).There is evidence of functional impairment due to weight issues (e.g., fatigue, poor mobility).Weight issues are not better explained by another medical condition (e.g., endocrine disorder).

5.2 Initial Assessment and Screening

At BrightPath Neuro, the initial assessment and screening for weight management is a comprehensive process aimed at understanding the individual’s current health status and the factors contributing to weight-related issues. The goals are to measure current weight status, identify contributing factors, and develop a personalised weight management plan. A variety of tools are used depending on age and clinical need, including Body Mass Index (BMI) from age 2+, Waist-to-Hip Ratio (12+), blood pressure monitoring, Food Frequency Questionnaires (5+), and Physical Activity Questionnaires (5+). Blood tests may also be conducted to detect underlying metabolic concerns, such as thyroid dysfunction. Psychological screening is a key component, with tools like the Emotional Eating Scale (EES) and Binge Eating Scale (BES) used to identify patterns of emotional or binge eating, and the Body Image Questionnaire assessing concerns around self-perception. The assessment also explores environmental and social factors, including family eating habits, access to exercise facilities, and any school or work-related barriers that may impact healthy eating and physical activity.

5.3 Identification of Underlying Causes

Medical Causes: Endocrine disorders (e.g., hypothyroidism, polycystic ovary syndrome).Medication side effects (e.g., antipsychotics, antidepressants).Genetic factors. Psychological Causes: Emotional eating linked to stress, anxiety, or depression. Disordered eating behaviours (e.g., binge eating, restriction).Poor body image or low self-esteem. Behavioural Causes: Sedentary lifestyle. Poor sleep quality. Irregular eating patterns. Environmental Causes: Lack of access to healthy food options. Financial barriers to exercise and health care. Family dynamics and cultural factors.

5.4 Development of a Personalised Weight Management Plan

Dietary Recommendations: Individualised calorie and macronutrient targets. Balanced meal plans including appropriate portion sizes. Reduction of high-sugar and high-fat foods. Physical Activity Recommendations: Minimum of 150 minutes of moderate-intensity exercise per week (if appropriate).Integration of exercise into daily life (e.g., walking, cycling).Referral to exercise therapists or physical trainers if needed. Psychological and Behavioural Interventions: Cognitive Behavioural Therapy (CBT) for emotional eating. Body image therapy and self-esteem building. Mindfulness-based approaches to eating. Medication Review: Adjust medications if weight gain or loss is a side effect. Explore medication alternatives if appropriate.

5.5 Monitoring and Review

Initial Review: Within 6 weeks of starting treatment. Ongoing Monitoring: Every 3 months there after. Track weight, BMI, and physical health markers. Adjust treatment plan based on patient response. Annual Review: A full review of the treatment plan should be conducted annually.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and treatment outcomes through quarterly audits. The Governance Lead will review prescribing decisions and patient outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Prescribing (weight) Policy (if medication is involved)

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent and prescribing medication when treating weight-related issues at BrightPath Neuro. Weight-related issues, including obesity, overweight, and underweight, are common among individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. Medications used to manage mental health or neurodevelopmental conditions can contribute to changes in appetite and metabolism, leading to weight gain or loss. Medication may be considered when non-pharmacological interventions (e.g., dietary adjustments, behavioural therapy, increased physical activity) have been insufficient or when the severity of weight-related issues poses a risk to the patient’s physical or mental health. The purpose of this policy is to: Ensure that patients and caregivers are fully informed about the nature, purpose, and risks of medication for weight-related issues. Ensure that prescribing decisions are evidence-based and tailored to the individual’s medical and psychological needs. Provide a clear framework for obtaining informed consent before prescribing medication. Ensure compliance with national guidelines and professional standards for prescribing. Establish a structured process for monitoring and reviewing prescribed medication.

2. Scope

This policy applies to: All patients at BrightPath Neuro being treated for weight-related difficulties. All staff involved in prescribing medication for weight-related difficulties, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Pharmacists, Dietitians, Mental Health Nurses, It covers: Consent for prescribing medication following a weight management assessment, Risk-benefit analysis of medication use for weight-related issues, Discussion of alternative treatment options, Documentation of consent and prescribing decisions, Monitoring and review of medication

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that prescribing decisions are clinically appropriate and supported by evidence. Respecting patient autonomy and the right to refuse medication., Providing patients and caregivers with balanced and accurate information about the benefits and risks of medication. Following national prescribing guidelines and professional standards. Ensuring that prescribing decisions are made in the best interests of the patient and tailored to their specific diagnosis and clinical needs.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations, General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of obesity, malnutrition, and eating disorders. British Dietetic Association (BDA) Guidelines – Professional standards for dietary advice and support. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Prescribing Considerations for Weight Management Medication

Non-Pharmacological First-Line Approach: Non-medication strategies should be attempted before medication is considered. First-line approaches include: Nutritional counselling and dietary adjustments, Behavioural therapy for emotional eating or disordered eating, Increasing physical activity levels, Improving sleep quality, Addressing psychological factors (e.g., stress, anxiety)When to Consider Medication: Medication may be considered if: Weight-related issues persist despite non-pharmacological interventions. Weight gain or loss is causing significant functional impairment (e.g., fatigue, joint pain, metabolic issues).Co-occurring conditions (e.g., ADHD, depression) are contributing to weight-related difficulties. The patient’s physical health is at risk due to extreme weight gain or loss. Types of Medication: The following medications may be considered depending on the nature of the weight-related issue: At BrightPath Neuro, medication may be considered as part of a tailored approach to managing weight-related issues, depending on the individual’s needs and underlying factors. Lisdexamfetamine and Methylphenidate may be used as appetite suppressants in certain cases of significant weight gain, though they are contraindicated in individuals with cardiovascular disease, hypertension, or anxiety. Orlistat, which works by reducing fat absorption, is suitable for individuals with obesity (BMI ≥ 28) but should not be used in those with malabsorption syndromes. Metformin may help reduce insulin resistance, particularly in cases where weight gain is linked to metabolic concerns or certain medications, but it is contraindicated in individuals with severe kidney impairment. In situations involving severe weight loss, medications such as Mirtazapine or Olanzapine may be considered to support appetite stimulation and weight gain, especially when accompanied by depression or psychosis. However, these are not recommended for individuals with diabetes or metabolic syndrome. All medication use is carefully reviewed on a case-by-case basis, ensuring risks and benefits are thoroughly considered.

5.2 Obtaining Informed Consent

Initial Discussion: Before prescribing medication, the clinician must provide the patient and caregiver with clear information about: The name, type, and purpose of the medication. The expected benefits of the medication. The potential side effects and risks (e.g., metabolic changes, mood changes).Any potential interactions with other medications. Alternative non-pharmacological treatments. The process for monitoring and reviewing medication. The potential for dependency or withdrawal symptoms (if applicable).The right to refuse or withdraw from treatment. Written Consent: Written consent must be obtained before initiating medication. The consent form must include: Medication name and dosage. Expected benefits and risks. Possible side effects. Monitoring and review schedule. Signature of the patient (or caregiver if applicable).Capacity to Consent: If the patient is over 16, they are presumed to have the capacity to consent unless there is evidence to the contrary. If the patient is under 16, consent must be obtained from a parent or legal guardian unless the patient is assessed as Gillick competent. If the patient lacks capacity, decisions must be made in their best interests under the Mental Capacity Act.

5.3 Alternative and Non-Pharmacological Interventions

Nutritional Counselling: Individualised meal plans. Education on portion control and balanced nutrition. Behavioural Therapy: Cognitive Behavioural Therapy (CBT) for emotional eating. Habit-reversal training. Exercise Recommendations: Moderate-intensity exercise for at least 150 minutes per week. Referral to an exercise specialist or personal trainer if needed. Psychological and Emotional Support: Address body image concerns. Provide coping strategies for stress and emotional regulation.5.4 Documentation and Record-Keeping Consent Records: All consent forms must be signed and dated. Copies of the consent form should be uploaded to the patient’s electronic health record. If consent is withdrawn, this should be documented clearly. Prescribing Records: All prescribed medication must be documented, including: Date prescribed, Dose and frequency, Duration of treatment, Reason for prescribing, Expected outcomes and monitoring plan

5.5 Monitoring and Review

Initial Monitoring: All medications for weight management must be reviewed within 6 weeks of initiation. Ongoing Review: Ongoing reviews should be conducted every 3 months. Adjust dosage based on weight changes, side effects, and patient response. Annual Review: A full review should be conducted annually. Alternative treatment options should be explored if no progress is made.

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Dietary and Lifestyle Assessment Policy

1. Purpose

This policy outlines the procedures and guidelines for conducting comprehensive dietary and lifestyle assessments for patients requiring weight management support at BrightPath Neuro. Weight management is crucial for overall physical and mental well-being. Individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia are at higher risk of developing unhealthy eating patterns, sedentary lifestyles, and weight-related challenges. BrightPath Neuro recognises that weight concerns may arise from multiple factors, including lifestyle behaviours, sensory preferences, medication side effects, and psychological or emotional factors. This policy aims to identify these contributors through a structured assessment process and support the development of a personalised weight management plan. The purpose of this policy is to: Establish a structured approach to conducting dietary and lifestyle assessments. Identify contributing factors to weight-related issues, including medical, emotional, and environmental factors. Promote evidence-based dietary and lifestyle interventions tailored to individual needs. Support patients and caregivers in adopting sustainable changes to improve weight, overall health, and well-being. Ensure compliance with national and professional standards.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for weight management support. All staff involved in conducting dietary and lifestyle assessments, including but not limited to: Medical Practitioners, Dietitians and Nutritionists, Non-Medical Prescribers (NMPs)Occupational Therapists, Clinical Psychologists, Mental Health Nurses, It covers: Dietary assessment process, Lifestyle and physical activity assessment, Identification of risk factors and barriers to healthy lifestyle changes, Development of an Individualised weight management plan, Patient and caregiver engagement in the process

3. Policy Statement

BrightPath Neuro is committed to: Conducting thorough dietary and lifestyle assessments as part of a holistic weight management approach. Ensuring that assessments are patient-centred, evidence-based, and culturally appropriate. Tailoring dietary and lifestyle recommendations to meet the individual needs of patients with neurodevelopmental conditions. Encouraging sustainable lifestyle changes that promote long-term health and well-being. Providing support to patients and caregivers throughout the weight management journey.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Guidelines on weight management, obesity, and healthy eating. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Equality Act 2010 – Ensures equal access to care and reasonable adjustments for individuals with disabilities. British Dietetic Association (BDA) Guidelines – Professional standards for dietary advice and support. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for dietary and lifestyle assessments may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Current weight and height, Recent weight changes, Co-occurring health conditions (e.g., diabetes, metabolic syndrome)Current medications and known side effects, History of eating habits and patterns, Physical activity levels

5.2 Dietary Assessment Process

The dietary assessment will be conducted by a qualified professional (e.g., dietitian or nutritionist) and will include: Food Intake History: Typical daily food and drink consumption, Frequency of meals and snacks, Portion sizes and patterns, Eating habits (e.g., late-night eating, emotional eating)Food preferences, dislikes, and sensory sensitivities, Dietary Quality and Nutritional Gaps: Micronutrient intake (e.g., vitamins, minerals)Consumption of processed foods and sugary snacks, Fiber, protein, and healthy fat intake, Hydration patterns, Cultural and Religious Considerations: Cultural preferences and dietary restrictions, Religious observances impacting dietary practices, Emotional and Psychological Eating Patterns: Emotional triggers for overeating or food avoidance, Stress-related eating behaviours, Binge eating or food restriction tendencies

5.3 Lifestyle and Physical Activity Assessment

Activity Levels: Typical daily activity, including walking, exercise, and household tasks, Barriers to physical activity (e.g., fatigue, motivation)Sedentary behaviours (e.g., screen time)Sleep and Rest Patterns: Sleep quality and duration, Sleep disturbances that may impact energy levels and appetite, Environmental and Social Factors: Family meal routines, Access to healthy food options, Financial considerations impacting food choices

5.4 Identification of Risk Factors

The assessment should identify factors that may contribute to weight issues, including: Medical factors: Medication side effects, underlying medical conditions. Psychological factors: Anxiety, low mood, or trauma-related eating patterns. Environmental factors: Limited access to fresh produce, limited cooking facilities. Behavioural factors: Emotional eating, binge eating, or food avoidance.

5.5 Development of a Personalised Weight Management Plan

Nutritional Goals: Create achievable dietary goals that reflect the patient’s lifestyle and needs. Promote balanced eating with a focus on: Increasing fiber, protein, and healthy fats, Reducing processed and high-sugar foods, Managing portion sizes, Encouraging regular meal patterns, Activity Goals: Develop achievable physical activity goals. Encourage fun, engaging activities to improve motivation. Provide referrals to exercise therapists if needed. Behavioural Goals: Implement strategies such as: Cognitive Behavioural Therapy (CBT) to address emotional eating. Mindful eating techniques. Strategies to manage triggers for overeating or food restriction. Family and Social Involvement: Where appropriate, involve family members to create a supportive home environment. Provide guidance for caregivers on encouraging healthy habits.

5.6 Monitoring and Review

Initial Review: Within 4–6 weeks of starting the treatment plan. Evaluate progress toward dietary and lifestyle goals. Ongoing Monitoring: Follow-up reviews should occur every 3 months. The review should assess: Weight trends (if appropriate)Changes in eating patterns, Emotional and psychological progress, Annual Review: An annual review of the entire dietary and lifestyle plan should be conducted. The review will include feedback from the patient, caregivers, and professionals involved in their care.

5.7 Referrals and Escalation

Where significant concerns are identified (e.g., extreme weight loss, suspected eating disorder), the patient should be referred to: GP or Medical Specialist for further investigation. Community Dietetic Services for complex nutritional support. Mental Health Support Services if emotional or psychological issues are a key factor.

6. Monitoring and Compliance

The Clinical Lead will monitor dietary and lifestyle assessments through quarterly audits. The Governance Lead will review dietary intervention outcomes to assess effectiveness.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Medication and Treatment Plan Policy (weight)

1. Purpose

This policy outlines the procedures and guidelines for developing and managing medication and treatment plans for patients with weight-related issues at BrightPath Neuro. Weight-related issues, including obesity, overweight, and underweight, are common in individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. In some cases, medication prescribed for ADHD, sleep, and emotional regulation may contribute to changes in appetite and weight. At BrightPath Neuro, weight management involves a combination of non-pharmacological (e.g., diet, exercise, and behavioural interventions) and pharmacological strategies where appropriate. Medication should only be prescribed when clinically indicated and after non-pharmacological interventions have been trialed or deemed unsuitable. The purpose of this policy is to: Ensure that medication and treatment plans for weight management are evidence-based and patient-centred. Provide a structured framework for developing, implementing, and reviewing treatment plans. Ensure that medications for weight management are prescribed and monitored safely and effectively. Ensure that patients and caregivers are actively involved in the treatment planning process. Establish a consistent process for monitoring treatment outcomes and adjusting plans as necessary.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for weight-related concerns. All staff involved in the development and management of weight-related treatment plans, including but not limited to: Medical Practitioners, Clinical Psychologists, Non-Medical Prescribers (NMPs)Dietitians and Nutritionists, Occupational Therapists, Pharmacists, Mental Health Nurses, It covers: Development of a comprehensive treatment plan for weight issues, Use of both non-pharmacological and pharmacological interventions, Patient and caregiver involvement in the treatment planning process, Monitoring and adjusting treatment plans based on patient response, Ensuring compliance with professional standards and guidelines

3. Policy Statement

BrightPath Neuro is committed to: Providing a comprehensive, patient-centred approach to managing weight-related issues. Ensuring that treatment plans are evidence-based, personalised, and clinically appropriate. Offering non-pharmacological interventions as the first-line approach wherever possible. Prescribing medication only when clinically indicated and following professional guidelines. Monitoring treatment outcomes regularly and adjusting the plan as needed. Ensuring that patients and caregivers are fully informed and involved in decision-making.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of obesity, malnutrition, and eating disorders. British Dietetic Association (BDA) Guidelines – Professional standards for dietary advice and support. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Development of a Comprehensive Treatment Plan

Initial Assessment: A full dietary, lifestyle, and medical assessment must be conducted before initiating a treatment plan. The assessment should include: Current weight and height (BMI)Medical history and current medications, Co-occurring mental health or neurodevelopmental conditions, Eating habits and patterns, Physical activity levels, Psychological factors (e.g., stress, emotional eating)Social and environmental factors impacting weight, Shared Decision-Making: The patient (or caregiver) must be actively involved in developing the treatment plan. The clinician should discuss: Available treatment options, Expected benefits and risks of each option, The patient’s preferences and goals, The need for flexibility and review of the plan over time, Treatment Plan Components: The treatment plan should include: Non-Pharmacological Interventions – First-line treatments to address lifestyle, behavioural, and environmental factors. Pharmacological Interventions – Only if clinically indicated. Nutritional and Physical Activity Recommendations – Tailored to the individual’s needs and capacity. Monitoring and Review Schedule – Regular reviews to evaluate treatment effectiveness and adjust as needed.

5.2 Non-Pharmacological Interventions

Nutritional Recommendations: Develop a balanced meal plan based on individual needs. Increase fiber, protein, and healthy fats while reducing processed foods. Encourage regular meal patterns (e.g., breakfast, lunch, dinner).Address any micronutrient deficiencies through diet or supplementation. Behavioural Therapy: Cognitive Behavioural Therapy (CBT) to address emotional eating., Habit-reversal training. Strategies to improve impulse control and develop healthy eating habits. Physical Activity Recommendations: Minimum of 150 minutes of moderate-intensity exercise per week (if appropriate).Encourage fun, low-pressure activities (e.g., swimming, walking, dancing).Referral to exercise therapists or physical trainers if needed. Psychological and Emotional Support: Address body image issues and emotional barriers to weight management. Provide coping strategies for stress and emotional regulation. Support for social and family-based challenges.

5.3 Pharmacological Interventions

When to Prescribe: Medication should only be considered when: Non-pharmacological interventions have been insufficient. Weight issues are causing significant functional impairment or health complications. The benefits of medication outweigh the risks. At BrightPath Neuro, a range of medications may be considered to support individuals with weight-related difficulties, depending on clinical need and underlying causes. Lisdexamfetamine and Methylphenidate may be used as appetite suppressants in selected cases of significant weight gain; however, they are contraindicated in individuals with cardiovascular disease, hypertension, or anxiety. Orlistat, which reduces fat absorption, is indicated for obesity (BMI ≥ 28) but is unsuitable for those with malabsorption syndromes. Metformin can help reduce insulin resistance, particularly when weight gain is linked to metabolic conditions or certain medications, but it should not be used in individuals with severe kidney impairment. For those experiencing severe weight loss, Mirtazapine or Olanzapine may be considered to increase appetite and support weight gain, especially in the context of depression or psychosis. However, both are contraindicated in cases involving metabolic syndrome, diabetes, or other significant metabolic concerns. Prescribing considerations include starting with the lowest effective dose, carefully monitoring for side effects or adverse reactions, and adjusting the dosage based on the patient’s individual response and tolerance. All prescribing decisions are made within a holistic, person-centred care plan.

5.4 Monitoring and Review

Regular Monitoring: All medications prescribed for weight management must be reviewed within 4–6 weeks of starting treatment. The review should assess: Effectiveness of the medication, Side effects and adverse reactions, Impact on weight, BMI, and overall health, Ongoing Review: Ongoing follow-ups should occur at least every 3 months. Adjust the medication or treatment plan based on patient response. Annual Review: A full review should be conducted annually. Alternative treatment options should be explored if no progress is made.

5.5 Documentation and Record-Keeping

All treatment plans and medication decisions must be documented in the patient’s record. Consent forms should be signed and filed. Changes to the treatment plan should be documented and signed by the patient (or caregiver).

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

074 Exercise and Physical Activity Guidance Policy (Weight Management Pathway)

1. Purpose

This policy sets out the procedures and guidelines for promoting and supporting exercise and physical activity as part of the Weight Management Pathway at BrightPath Neuro. Exercise and physical activity are essential components of a comprehensive weight management plan. Regular exercise helps regulate metabolism, improve mood, support emotional well-being, and enhance overall physical and mental health. For individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia, exercise can play a crucial role in improving emotional regulation, executive functioning, motor skills, and social interaction. BrightPath Neuro recognises that weight-related challenges often arise from a combination of medical, psychological, behavioural, and environmental factors. Exercise and physical activity recommendations should therefore be tailored to the individual's needs and capacity as part of a structured weight management plan. The purpose of this policy is to: Ensure that exercise guidance is an integrated part of the weight management pathway. Provide a structured and evidence-based approach to developing personalised exercise plans. Identify and address barriers to physical activity, including sensory, emotional, and environmental challenges. Encourage sustainable and enjoyable exercise patterns that support long-term health outcomes. Ensure compliance with national guidelines and professional standards for physical activity and weight management.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for weight-related issues as part of the Weight Management Pathway. All staff involved in conducting exercise assessments and providing physical activity guidance, including but not limited to: Medical Practitioners, Occupational Therapists, Physiotherapists, Dietitians and Nutritionists, Clinical Psychologists, Mental Health Nurses, It covers: Initial assessment and screening for physical activity levels, Development of an Individualised exercise plan, Monitoring and adjusting patient progress, Providing guidance on exercise safety and injury prevention

3. Policy Statement

BrightPath Neuro is committed to: Promoting exercise and physical activity as essential components of weight management and overall health. Providing patient-centred, evidence-based exercise plans that are tailored to the individual’s capacity and personal goals. Encouraging sustainable and enjoyable physical activity patterns. Identifying and addressing barriers to physical activity through practical support. Monitoring patient progress and adjusting exercise recommendations as necessary. Ensuring that patients and caregivers are fully informed and involved in the development of exercise plans.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations on weight management and exercise therapy. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Equality Act 2010 – Ensures equal access to exercise opportunities and reasonable adjustments for individuals with disabilities. World Health Organization (WHO) Physical Activity Guidelines – Global guidelines for minimum levels of physical activity for different age groups. British Association of Sports and Exercise Medicine (BASEM) Guidelines – Professional standards for physical activity and exercise therapy.

5. Procedure

5.1 Initial Assessment and Screening

At BrightPath Neuro, the initial assessment and screening process for physical activity guidance begins upon referral, which may come from General Practitioners (GPs), schools, educational psychologists, SENCOs, mental health services (e.g., CAMHS), social care services, or via self-referral for those aged 18 and above. Each referral is reviewed within five working days by the Clinical Lead or a senior clinician. The referral should include details on current physical activity levels, any co-occurring health conditions (such as cardiovascular or musculoskeletal issues), relevant psychological factors, and environmental or social barriers to exercise. All patients must complete a Physical Activity Readiness Questionnaire (PAR-Q) before beginning any exercise plan to identify potential risks or contraindications. If the PAR-Q indicates any concerns, medical clearance must be obtained prior to proceeding. Additional screening tools may include the International Physical Activity Questionnaire (IPAQ) for individuals aged 15 and over, which measures overall activity levels, and a Strength and Flexibility Assessment used across all age groups to establish baseline physical ability. These steps help ensure that any recommended activity is safe, appropriate, and tailored to the individual's needs.

5.2 Development of a Personalised Exercise Plan

At BrightPath Neuro, the development of a personalised exercise plan is based on a thorough understanding of the individual’s current fitness level, health status, physical limitations, personal goals, motivation, age, gender, cultural background, and neurodevelopmental profile—including sensory sensitivities and motor coordination. The plan should incorporate a variety of exercise types to support holistic physical development and wellbeing. This may include aerobic exercises (e.g., walking, swimming, cycling, dancing) to boost cardiovascular health and mood; strength training (e.g., bodyweight exercises, resistance bands, light weights) to enhance muscle and bone strength; flexibility and mobility activities (e.g., yoga, Pilates, stretching) to improve range of motion and reduce injury risk; coordination and balance activities (e.g., Tai Chi, balance boards, gymnastics) to develop motor control; and team or social sports (e.g., football, basketball, netball) to promote social interaction and teamwork. Exercise plans should follow WHO guidelines, recommending at least 60 minutes of moderate-to-vigorous activity per day for children and adolescents, and 150 minutes of moderate-intensity activity per week for adults. Intensity should be increased gradually, taking into account the individual's progress and tolerance. Behavioural and environmental adjustments are essential for neurodivergent individuals. For those with ASC, this may include reducing noise, avoiding bright lights, and providing structured, predictable sessions. For individuals with ADHD, shorter sessions with frequent breaks and engaging, high-energy activities may be more effective. Each plan is designed to be both safe and person-centred, promoting long-term participation and health outcomes.

5.3 Monitoring and Review

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting the exercise plan. Adjustments should be made based on the patient’s feedback and progress. Ongoing Monitoring: Follow-up reviews should occur every 3 months. The following should be assessed: Changes in physical activity levels, Physical and mental health outcomes, Barriers to exercise, Motivation and adherence to the plan, Annual Review: A full review of the exercise plan should be conducted annually. Adjustments should be made based on patient response and any changes in health status.

5.4 Safety and Risk Management

Injury Prevention: Patients should be educated on proper exercise techniques. Warm-up and cool-down sessions should be included. Emergency Response: Staff involved in exercise delivery should be trained in: Basic first aid, Cardiopulmonary resuscitation (CPR)

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and patient outcomes. The Governance Lead will conduct quarterly audits of exercise plans and patient progress.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (mood)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for mood and mental health at BrightPath Neuro. Mental health is a critical component of overall well-being and significantly impacts emotional, cognitive, and physical functioning. Individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia are at an increased risk of developing mental health challenges, including anxiety, depression, emotional dysregulation, and low self-esteem. At BrightPath Neuro, early identification of mood and mental health issues through structured assessment and screening is essential for developing effective, personalised intervention plans. This policy aims to provide a consistent and evidence-based framework for assessing mood and mental health, identifying risk factors, and developing targeted interventions. The purpose of this policy is to: Ensure that mood and mental health issues are identified early and accurately. Establish a consistent and structured approach to mental health screening and assessment. Identify underlying causes and contributing factors to mental health difficulties. Develop person-centred, evidence-based treatment and intervention plans. Ensure that patients and caregivers are actively involved in the assessment process.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for mood and mental health support. All staff involved in conducting mental health assessments and developing treatment plans, including but not limited to: Medical Practitioners, Clinical Psychologists, Non-Medical Prescribers (NMPs)Occupational Therapists, Mental Health Nurses, Cognitive Behavioural Therapists, It covers: Referral and triage for mood and mental health assessments, Screening and initial assessment process, Identification of risk factors and underlying causes, Development of Individualised treatment and support plans, Communication of findings and recommendations to the patient and caregivers

3. Policy Statement

BrightPath Neuro is committed to: Providing a person-centred, trauma-informed approach to mental health assessment and support. Using validated and evidence-based assessment tools to accurately identify mood and mental health issues. Ensuring that mental health assessments are tailored to the individual’s neurodevelopmental profile and personal circumstances. Addressing both psychological and environmental factors that contribute to mental health issues. Providing transparent and accessible information about the assessment process and outcomes. Developing personalised, evidence-based intervention plans that promote long-term emotional well-being.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of mental health conditions. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health assessment and treatment. British Psychological Society (BPS) Guidelines – Professional standards for psychological assessment and treatment. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for mood and mental health assessments may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting mental health concerns (e.g., mood changes, anxiety, emotional outbursts)Co-occurring mental health and neurodevelopmental conditions, Relevant medical and psychiatric history, Current medication and known side effects, Recent life events or trauma, Family and social context, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for a mental health assessment. The mental health difficulties are impacting the individual’s functioning or quality of life. Symptoms are not better explained by an underlying medical condition.

5.2 Initial Assessment and Screening

At BrightPath Neuro, the initial assessment and screening for mood and mental health difficulties aims to identify emotional challenges, understand their impact on daily functioning, explore underlying causes, and inform the development of a personalised treatment plan. A range of validated tools is used depending on age and clinical presentation. These include the PHQ-9 and GAD-7 (ages 12+) to screen for symptoms of depression and anxiety, the Mood and Feelings Questionnaire (MFQ) for ages 6–18 to assess emotional distress, and the Strengths and Difficulties Questionnaire (SDQ) for ages 4–17 to evaluate emotional and behavioural issues. Additional tools include the Emotional Regulation Questionnaire (ERQ) (12+), the Child Behaviour Checklist (CBCL) (6–18), and the Adverse Childhood Experiences (ACE) Questionnaire, which is used across all ages to identify early life trauma. A comprehensive clinical interview is also conducted with the patient—and with caregivers if appropriate—to explore the individual’s current emotional state, mental health history, impact on daily life, family and social support, coping strategies, and personal strengths. The assessment also considers a range of psychological and environmental factors, such as life stressors (e.g., bullying, academic pressure), family dynamics, financial or housing instability, and—for individuals with ASC—sensory sensitivities and overstimulation. This holistic approach ensures that care is responsive, personalised, and focused on long-term wellbeing.

5.3 Diagnosis and Communication of Results

Diagnostic Criteria: A diagnosis may be made if the patient meets the criteria for a mood or mental health condition under:DSM-5 – Diagnostic and Statistical Manual of Mental DisordersICD-11 – International Classification of Diseases, Outcome of Assessment: A full assessment report should be completed within 14 working days of the final assessment session. The report should include: Summary of presenting issues, Diagnostic findings (if applicable)Strengths and weaknesses, Recommended adjustments and interventions, Patient and Caregiver Feedback: A face-to-face or virtual meeting will be held to explain the results. A copy of the report will be provided to the patient and caregiver.

5.4 Development of a Personalised Treatment Plan

Treatment Recommendations: Psychological therapy (e.g., CBT, DBT)Medication (if clinically indicated)Social support, Sensory and environmental adjustments, Psychoeducation for the patient and caregiver, Follow-Up: A follow-up appointment should be scheduled within 6 weeks of diagnosis.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and treatment outcomes. The Governance Lead will review mental health assessment outcomes and reports quarterly.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Prescribing (mood) Policy (if medication is involved)

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent and prescribing medication for the treatment of mood and mental health conditions at BrightPath Neuro. Mood-related issues, including depression, anxiety, emotional dysregulation, and low mood, are common among individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. In some cases, psychological interventions alone may be insufficient to manage mood-related symptoms, and medication may be considered as part of a comprehensive treatment plan. The decision to prescribe medication for mood-related issues must be made carefully, considering the individual’s neurodevelopmental profile, co-occurring conditions, and personal preferences. The process of prescribing medication should follow national guidelines and include a thorough discussion of the risks, benefits, and alternative treatment options with the patient and caregiver (if applicable).The purpose of this policy is to: Ensure that prescribing decisions are clinically appropriate and evidence-based. Provide patients and caregivers with clear information about the benefits and risks of medication. Ensure that patients (and caregivers, if applicable) give informed consent before starting medication. Ensure that prescribing decisions align with the patient’s best interests and treatment goals. Establish a structured process for monitoring and reviewing prescribed medication.

2. Scope

This policy applies to: All patients at BrightPath Neuro receiving medication for mood and mental health issues. All staff involved in prescribing medication for mood and mental health conditions, including but not limited to: Medical Practitioners, Non-Medical Prescribers (NMPs)Clinical Psychologists, Pharmacists, Mental Health Nurses, It covers: Consent for prescribing medication following a mood and mental health assessment. Risk-benefit analysis of medication use for mood-related issues. Discussion of alternative treatment options. Documentation of consent and prescribing decisions. Monitoring and review of medication.

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that prescribing decisions are clinically appropriate and supported by evidence. Respecting patient autonomy and the right to refuse medication. Providing patients and caregivers with balanced and accurate information about the benefits and risks of medication. Following national prescribing guidelines and professional standards. Ensuring that prescribing decisions are made in the best interests of the patient and tailored to their specific diagnosis and clinical needs. Regularly reviewing the effectiveness and safety of prescribed medication.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of depression, anxiety, and mood disorders. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Prescribing Considerations for Mood-Related Medication

At BrightPath Neuro, non-pharmacological interventions are prioritised as the first-line approach for managing mood-related difficulties unless there is a clear clinical urgency. Initial strategies may include Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), mindfulness and relaxation techniques, lifestyle changes (such as improving sleep, physical activity, and diet), emotional regulation techniques, and social or peer support. Medication may be considered when mood symptoms persist despite these interventions, when there is significant functional impairment (e.g., difficulty attending school, work, or engaging socially), when the severity of symptoms poses a risk (such as self-harm or suicidal ideation), when co-occurring conditions like anxiety or depression are affecting progress, or when the potential benefits of medication outweigh the risks. A range of medications may be used depending on the individual’s presentation. Sertraline and Fluoxetine are SSRIs commonly prescribed for depression, anxiety, and emotional dysregulation, though caution is needed in cases of severe liver impairment or risk of serotonin syndrome. Mirtazapine may be used when depression is accompanied by sleep disturbances, but is unsuitable for individuals with metabolic syndrome or concerns about weight gain. Venlafaxine, an SNRI, may be indicated for severe depression or anxiety, though it is contraindicated in those with hypertension or cardiovascular disease. For physical symptoms of anxiety, Propranolol may be helpful unless the patient has asthma or bradycardia. Clonidine, an alpha-adrenergic agonist, may be used for emotional dysregulation and hyperarousal, but should not be used in patients with hypotension or heart block. All prescribing decisions are made on a case-by-case basis, with careful monitoring of risks, benefits, and treatment response.

5.2 Obtaining Informed Consent

Initial Discussion: Before prescribing medication, the clinician must provide the patient and caregiver (if applicable) with clear information about: The name, type, and purpose of the medication. The expected benefits of the medication. The potential side effects and risks (e.g., mood changes, weight gain).Any potential interactions with other medications.Alternative non-pharmacological treatments.The process for monitoring and reviewing medication.The right to refuse or withdraw from treatment.Written Consent:Written consent must be obtained before initiating medication.The consent form must include: Medication name and dosage.Expected benefits and risks.Possible side effects.Monitoring and review schedule.Signature of the patient (or caregiver if applicable).Capacity to Consent:If the patient is over 16, they are presumed to have the capacity to consent unless there is evidence to the contrary.If the patient is under 16, consent must be obtained from a parent or legal guardian unless the patient is assessed as Gillick competent.If the patient lacks capacity, decisions must be made in their best interests under the Mental Capacity Act.

5.3 Monitoring and Review

Initial Monitoring: All medications for mood and mental health should be reviewed within 4–6 weeks of initiation. The review should assess: Effectiveness of the medication, Side effects and adverse reactions, Patient feedback and satisfaction, Ongoing Review: Ongoing reviews should occur every 3 months. Adjust dosage or medication type based on patient response. Monitor mental health stability and emotional well-being. Annual Review: A full review of medication use and mental health status should be conducted annually. Alternative treatment options should be explored if progress is limited.

5.4 Documentation and Record-Keeping

Consent Forms: All consent forms must be signed and stored in the patient’s record. Prescribing Records: Date prescribed, dose, and frequency, Reason for prescribing, Monitoring and review schedule

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Psychological and Emotional Wellbeing Policy

1. Purpose

This policy sets out the procedures and guidelines for promoting and supporting psychological and emotional wellbeing at BrightPath Neuro. Psychological and emotional wellbeing are critical components of overall mental health and quality of life. Individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia often face unique challenges that can impact emotional regulation, stress management, self-esteem, and social interaction. Left unaddressed, these challenges may contribute to long-term mental health issues such as anxiety, depression, emotional dysregulation, and low self-confidence. BrightPath Neuro is committed to providing a person-centred, trauma-informed approach to psychological and emotional wellbeing. This includes creating a supportive environment, offering evidence-based interventions, and ensuring that patients feel empowered to manage their emotional health. The purpose of this policy is to: Establish a structured and evidence-based approach to promoting emotional and psychological wellbeing. Provide patients and caregivers with access to psychological support and interventions. Identify early signs of emotional and psychological distress. Develop personalised plans to support emotional regulation and coping skills. Monitor and review psychological and emotional wellbeing regularly.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for psychological and emotional support. All staff involved in providing mental health and emotional wellbeing support, including but not limited to: Medical Practitioners, Clinical Psychologists, Cognitive Behavioural Therapists, Occupational Therapists, Mental Health Nurses, Non-Medical Prescribers (NMPs)It covers: Screening and assessment of psychological and emotional wellbeing. Development of Individualised emotional wellbeing plans. Identification of early signs of psychological distress. Psychological interventions and coping strategies. Family and caregiver involvement in emotional wellbeing plans.

3. Policy Statement

BrightPath Neuro is committed to: Promoting emotional and psychological wellbeing as a key part of overall health. Ensuring that patients have access to appropriate psychological and emotional support. Delivering evidence-based interventions that are personalised to the patient’s needs. Providing a safe and supportive environment for patients and caregivers. Encouraging self-awareness and emotional resilience. Ensuring that staff are trained and supported to manage psychological and emotional issues effectively.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of mental health conditions. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for psychological care. British Psychological Society (BPS) Guidelines – Professional standards for psychological assessment and treatment. Equality Act 2010 – Ensures equal access to mental health and emotional wellbeing services. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Assessment and Screening

At BrightPath Neuro, the assessment and screening process for psychological and emotional wellbeing begins with referrals, which may come from GPs, schools, educational psychologists, SENCOs, mental health services (e.g., CAMHS), social care services, self-referrals (for those aged 18 and above), or caregivers in the case of children or dependent adults. All referrals are reviewed within five working days by the Clinical Lead or a senior clinician. Key information required in the referral includes details of the presenting emotional and psychological concerns (such as mood changes or emotional outbursts), relevant medical and psychiatric history, current medications and side effects, and the individual’s family, social context, and any recent trauma or life events. A range of validated screening tools is used to assess emotional wellbeing, including the PHQ-9 and GAD-7 (12+ years) for symptoms of depression and anxiety, the Mood and Feelings Questionnaire (MFQ) (6–18 years), and the Strengths and Difficulties Questionnaire (SDQ) (4–17 years) to assess emotional and behavioural concerns. Additional tools such as the Emotional Regulation Questionnaire (ERQ) (12+ years) and the Adverse Childhood Experiences (ACE) Questionnaire (all ages) are used to explore emotional regulation and past trauma. A comprehensive clinical interview is then conducted to explore the individual’s current emotional state, psychological symptoms, and the impact of emotional wellbeing on daily life. The interview also examines coping strategies, emotional regulation skills, family and social support, and environmental factors such as school, work, or home circumstances, allowing for a holistic understanding of the individual's needs.

5.2 Development of a Personalised Emotional Wellbeing Plan

Treatment Recommendations: The emotional wellbeing plan should address: Emotional regulation techniques, Psychological therapy (e.g., CBT, DBT)Coping strategies and self-help tools, Family and caregiver involvement, Social skills training (if applicable)Sensory and environmental adjustments, Psychological Interventions: Evidence-based interventions should be offered based on the patient’s needs: Cognitive Behavioural Therapy (CBT) – To address negative thought patterns and promote emotional regulation. Dialectical Behaviour Therapy (DBT) – To support emotional regulation and distress tolerance. Mindfulness and Relaxation Therapy – To reduce stress and anxiety. Exposure Therapy – To reduce avoidance behaviours and anxiety. Environmental Adjustments: Adjustments to the school or work environment should be recommended if needed. Support for sensory sensitivities should be provided. Crisis Planning: If the patient is at risk of self-harm or emotional crisis, a crisis plan should be developed. Emergency contact information should be recorded and shared with caregivers (if applicable).

5.3 Monitoring and Review

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting the emotional wellbeing plan. The following should be assessed: Changes in emotional wellbeing, Response to psychological interventions, Patient and caregiver feedback, Ongoing Monitoring: Follow-up reviews should occur every 3 months. The review should assess: Psychological symptoms and emotional state, Effectiveness of emotional regulation strategies, Changes in social or environmental factors, Annual Review: A full review of the emotional wellbeing plan should be conducted annually. Adjustments should be made based on patient response and any changes in mental health status.

5.4 Documentation and Record-Keeping

Wellbeing Plans: All wellbeing plans must be documented in the patient’s health record. Any changes to the plan should be recorded and signed by the clinician. Progress Reports: Patient progress and feedback should be documented at each review session. Outcome measures should be recorded using standardised tools.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and patient outcomes. The Governance Lead will conduct quarterly audits of emotional wellbeing plans and patient progress.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Medication and Treatment Plan Policy (mood)

1. Purpose

This policy sets out the procedures and guidelines for developing and managing medication and treatment plans for patients receiving support for mood and mental health conditions at BrightPath Neuro. Mood and mental health conditions, including depression, anxiety, emotional dysregulation, and low mood, are common among individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. When non-pharmacological treatments (e.g., therapy, lifestyle changes) are insufficient in managing symptoms, medication may be considered as part of a comprehensive treatment plan. The decision to prescribe medication for mood and mental health issues requires a careful, evidence-based approach, ensuring that the benefits of medication outweigh the risks. The treatment plan should be tailored to the individual’s psychological, social, and medical needs and adjusted over time based on patient response and tolerance. The purpose of this policy is to: Ensure that medication and treatment plans for mood and mental health issues are evidence-based and patient-centred. Provide a structured framework for developing, implementing, and reviewing treatment plans. Ensure that medications for mood and mental health are prescribed and monitored safely and effectively. Ensure that patients and caregivers are actively involved in the treatment planning process. Establish a consistent process for monitoring treatment outcomes and adjusting plans as necessary.

2. Scope

This policy applies to: All patients at BrightPath Neuro receiving medication for mood and mental health conditions. All staff involved in the development and management of mood-related treatment plans, including but not limited to: Medical Practitioners, Clinical Psychologists, Non-Medical Prescribers (NMPs)Occupational Therapists, Mental Health Nurses, Pharmacists, It covers: Development of a comprehensive treatment plan for mood and mental health issues. Use of both non-pharmacological and pharmacological interventions. Patient and caregiver involvement in the treatment planning process. Monitoring and adjusting treatment plans based on patient response. Ensuring compliance with professional standards and guidelines.

3. Policy Statement

BrightPath Neuro is committed to: Providing a comprehensive, patient-centred approach to managing mood and mental health issues. Ensuring that treatment plans are evidence-based, personalised, and clinically appropriate. Offering non-pharmacological interventions as the first-line approach wherever possible. Prescribing medication only when clinically indicated and following professional guidelines. Monitoring treatment outcomes regularly and adjusting the plan as needed. Ensuring that patients and caregivers are fully informed and involved in decision-making.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of depression, anxiety, and mood disorders. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Guidelines on prescribing and professional standards. Nursing and Midwifery Council (NMC) Code of Conduct – Standards for professional practice. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Development of a Comprehensive Treatment Plan

Initial Assessment: A full psychological and medical assessment must be conducted before initiating a treatment plan. The assessment should include: Presenting mood and mental health symptoms, Medical history and current medications, Co-occurring neurodevelopmental and mental health conditions, Emotional and psychological state, Functional impact on daily life, Family and social factors, Sensory sensitivities (if applicable)Shared Decision-Making: The patient (or caregiver) must be actively involved in developing the treatment plan. The clinician should discuss: Available treatment options, Expected benefits and risks of each option, The patient’s preferences and goals, The need for flexibility and review of the plan over time, Treatment Plan Components: The treatment plan should include: Non-Pharmacological Interventions – First-line treatments to address emotional, behavioural, and environmental factors. Pharmacological Interventions – Only if clinically indicated and when psychological interventions alone are insufficient. Psychological Support – Emotional regulation and coping strategies. Environmental and Social Support – Adjustments at school, work, or home. Monitoring and Review Schedule – Regular reviews to evaluate treatment effectiveness and adjust as needed.

5.2 Non-Pharmacological Interventions

Psychological Interventions: Cognitive Behavioural Therapy (CBT)Dialectical Behaviour Therapy (DBT)Mindfulness-Based Stress Reduction (MBSR)Emotional regulation training, Social skills training, Trauma-informed care approaches, Behavioural Interventions: Lifestyle adjustments (e.g., improved sleep hygiene, increased physical activity)Stress management techniques, Coping skills and relaxation strategies, Social and Environmental Adjustments: Adjustments at home, school, or work, Peer support and group therapy options, Family involvement and psychoeducation

5.3 Pharmacological Interventions

At BrightPath Neuro, pharmacological interventions for mental health conditions are considered only when non-pharmacological strategies—such as therapy, lifestyle adjustments, and psychological support—have not been effective, or when symptoms cause significant functional impairment, health complications, or place the individual at risk of harm (e.g., self-harm or suicidal ideation). Medication may also be appropriate when co-occurring conditions like anxiety or depression require pharmacological support. A variety of medications may be prescribed depending on the nature of the mental health concern. Sertraline and Fluoxetine, both SSRIs, are commonly used to treat depression, anxiety, and emotional dysregulation, though caution is advised in cases of severe liver or renal impairment, or where there is a risk of serotonin syndrome due to interactions. Mirtazapine, a NaSSA, is suitable for individuals with depression accompanied by sleep disturbances, but may not be appropriate for those with metabolic syndrome or concerns about weight gain. Venlafaxine, an SNRI, is considered for severe depression or anxiety, but is contraindicated in those with hypertension or cardiovascular disease. For managing physical symptoms of anxiety such as rapid heartbeat, Propranolol may be prescribed, unless the individual has asthma or bradycardia. Clonidine, an alpha-adrenergic agonist, may help with emotional dysregulation and hyperarousal, but should be avoided in cases of hypotension or heart block. All prescribing decisions are made on a case-by-case basis, starting with the lowest effective dose, and include close monitoring for side effects and effectiveness.

5.4 Monitoring and Review

Initial Monitoring: Medication should be reviewed within 4–6 weeks of starting treatment. The review should assess: Effectiveness of the medication, Side effects and adverse reactions, Patient feedback and satisfaction, Ongoing Review: Ongoing reviews should occur every 3 months. Adjust dosage or medication type based on patient response. Monitor emotional wellbeing and functional outcomes. Annual Review: A full review should be conducted annually. Alternative treatment options should be explored if no progress is made.

5.5 Documentation and Record-Keeping

Treatment Plans: All treatment plans must be documented in the patient’s health record. Changes to the plan must be documented and signed by the clinician. Consent Records: Written consent for medication must be obtained and stored securely.

6. Monitoring and Compliance

The Clinical Lead will monitor treatment plan completion rates and patient outcomes. The Governance Lead will conduct quarterly audits of medication prescribing and outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Therapeutic Interventions Policy (e.g., CBT, DBT, EMDR)

1. Purpose

This policy sets out the procedures and guidelines for delivering structured and evidence-based therapeutic interventions at BrightPath Neuro, including Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), and other psychological therapies. Individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia are at increased risk of developing mental health challenges, including anxiety, depression, emotional dysregulation, trauma-related symptoms, and low self-esteem. Therapeutic interventions are essential in addressing these difficulties and improving emotional, cognitive, and social functioning. The purpose of this policy is to: Establish a structured and evidence-based framework for delivering therapeutic interventions. Ensure that therapy options are personalised and aligned with the individual’s needs and preferences. Promote the use of therapies supported by clinical research and best practice guidelines. Ensure that therapists are trained and competent to deliver therapeutic interventions safely and effectively. Monitor treatment outcomes and adjust therapeutic approaches as needed.

2. Scope

This policy applies to: All patients at BrightPath Neuro referred for psychological and therapeutic support. All staff involved in delivering or supporting therapeutic interventions, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Occupational Therapists, Non-Medical Prescribers (NMPs)Mental Health Nurses, Counsellors and Psychotherapists, It covers: Referral and triage for psychological therapy. Selection of appropriate therapeutic intervention. Delivery of therapy. Monitoring and adjusting therapeutic interventions. Communication of treatment outcomes with patients and caregivers (where applicable).

3. Policy Statement

BrightPath Neuro is committed to: Providing a range of evidence-based therapeutic interventions tailored to the individual’s needs. Ensuring that patients and caregivers are fully informed about the nature and goals of therapy. Delivering therapy in a safe, consistent, and professional manner. Ensuring that therapists are appropriately trained, supervised, and supported. Regularly monitoring and evaluating therapy outcomes. Encouraging a trauma-informed and person-centred approach to care.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies and mental health treatments. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for psychological therapy may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues, Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: The symptoms meet the criteria for psychological therapy. Symptoms are having a significant impact on daily life or functioning. The patient agrees to engage in therapy and understands the therapy process.

5.2 Selection of Therapeutic Intervention

At BrightPath Neuro, the selection of therapeutic intervention is guided by a comprehensive understanding of the individual's needs, taking into account their clinical presentation, diagnosis, severity and complexity of symptoms, developmental stage, cognitive capacity, and any previous response to therapy. Patient preferences and cultural considerations are also central to the decision-making process to ensure therapy is both effective and person-centred. A range of evidence-based therapeutic interventions is offered. Cognitive Behavioural Therapy (CBT) is used to address negative thought patterns and behaviours, commonly applied in cases of depression, anxiety, emotional dysregulation, and trauma. Dialectical Behaviour Therapy (DBT) supports individuals with emotional regulation, self-harm, and interpersonal difficulties, particularly where borderline personality traits are present. Eye Movement Desensitization and Reprocessing (EMDR) is offered to reduce distress linked to traumatic memories, often used in PTSD. Mindfulness-Based Cognitive Therapy (MBCT) and Acceptance and Commitment Therapy (ACT) help with emotional awareness, stress reduction, and psychological flexibility, beneficial for anxiety, depression, and stress-related difficulties. For individuals with more mild mood or adjustment disorders, Solution-Focused Brief Therapy (SFBT) encourages the development of strengths and positive solutions. Play Therapy is used with children to support emotional expression and communication, particularly in the context of trauma or emotional distress. Psychodynamic Therapy is offered to explore unconscious conflicts and attachment issues, often suitable for chronic depression and relationship difficulties. Each therapeutic pathway is tailored to promote meaningful outcomes and long-term emotional wellbeing.

5.3 Delivery of Therapy

Initial Therapy Session: The therapist must explain: The goals and structure of therapy. Expected duration and frequency of sessions. Confidentiality and its limits. Patient rights and responsibilities. Therapeutic Process: Sessions should be conducted in a consistent and structured manner. Goals and progress should be reviewed regularly. Sessions should provide a safe and supportive environment. The therapist should adapt the intervention to the patient's neurodevelopmental profile. Crisis Response: If a patient becomes distressed or discloses suicidal ideation, the therapist should: Assess immediate risk. Follow the BrightPath Neuro Crisis Management Protocol. Contact emergency services if needed.

5.4 Monitoring and Review

Progress Monitoring: Patient progress should be assessed using validated outcome measures such as: PHQ-9 (Depression)GAD-7 (Anxiety)CORE-OM (Overall mental health outcomes)Feedback should be sought from the patient (and caregivers, if applicable).Ongoing Review: Therapy plans should be reviewed every 6–8 weeks. Adjustments should be made based on patient response and therapist feedback. If therapy is not progressing, alternative approaches should be explored. Termination of Therapy: Therapy may be terminated when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate. A discharge summary should be provided to the patient.

5.5 Documentation and Record-Keeping

All therapy sessions and treatment plans must be documented in the patient’s health record. Consent forms and confidentiality agreements should be stored securely.

6. Monitoring and Compliance

The Clinical Lead will monitor therapy completion rates and patient outcomes. The Governance Lead will conduct quarterly audits of therapy records and outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Referral and Signposting Policy for Mood and Mental Health

1. Purpose

This policy sets out the procedures and guidelines for handling referrals and signposting for mood and mental health issues at BrightPath Neuro. BrightPath Neuro provides structured, evidence-based assessment, diagnosis, and treatment for individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. However, BrightPath Neuro is not a crisis service and does not provide emergency mental health care or crisis management. If a patient presents with an acute mental health crisis (e.g., suicidal ideation, psychosis, self-harm requiring immediate intervention), BrightPath Neuro will refer the individual to an appropriate emergency or specialist mental health service. The purpose of this policy is to: Provide a clear process for managing referrals for mood and mental health issues. Ensure that patients presenting with acute mental health needs are signposted to appropriate services. Ensure that patients receive timely and appropriate care. Maintain professional boundaries and define the limits of BrightPath Neuro’s role.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for mood and mental health issues. All staff involved in triaging, assessing, or managing referrals for mood and mental health support, including but not limited to: Medical Practitioners, Clinical Psychologists, Non-Medical Prescribers (NMPs)Mental Health Nurses, Occupational Therapists, Cognitive Behavioural Therapists, It covers: Referral and triage of mood and mental health issues. Identification of urgent and non-urgent mental health needs. Signposting to specialist or emergency services where needed. Communication of decisions to patients and caregivers.

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that referrals for mood and mental health issues are managed in a professional, consistent, and timely manner. Providing appropriate care within the scope of BrightPath Neuro’s services. Signposting patients to alternative or specialist services when care requirements exceed BrightPath Neuro’s remit. Maintaining patient safety and ensuring that high-risk cases are referred to appropriate services without delay. Respecting patient autonomy and confidentiality when making referrals.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the diagnosis and treatment of mental health conditions. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral Process

Referral Sources: Referrals for mood and mental health issues may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting mental health issues (e.g., anxiety, depression, emotional dysregulation)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, Risk factors (e.g., self-harm, suicidal ideation)Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for a mental health assessment or therapeutic intervention. Symptoms are not acute or life-threatening. The patient’s mental health needs fall within the scope of BrightPath Neuro’s services. Rejection of Referral: A referral may be rejected if: The patient requires emergency or crisis-level mental health support. The presenting issue falls outside BrightPath Neuro’s scope of care. The patient refuses to engage in the treatment process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Risk Assessment and Management

High-Risk Presentations: If a patient presents with any of the following, the case should be treated as high-risk: Active suicidal ideation or intent. Severe self-harm requiring medical attention. Psychotic symptoms (e.g., hallucinations, delusions).Severe emotional dysregulation with a risk of harm to self or others .Immediate Actions: If a patient presents with a high-risk situation: Contact emergency services (999) or the local crisis team. Ensure the patient is not left alone until support arrives. Document the incident in the patient’s record, including actions taken. Signposting to Crisis Services: If a patient requires immediate mental health support, BrightPath Neuro will signpost them to:999 – Emergency services for immediate risk of harm. NHS 111 – For urgent but non-life-threatening mental health support. Local Crisis Team – Based on the patient’s location. Samaritans – 24-hour emotional support. ChildLine – Support for children and young people.

5.3 Non-Urgent Referrals

Non-Urgent Presentations: Non-urgent cases include: Mild to moderate depression or anxiety. Emotional dysregulation without active suicidal thoughts. Social and interpersonal difficulties. Mild behavioural issues. Referral to Internal Services: Patients with non-urgent mood and mental health needs may be referred to: Cognitive Behavioural Therapy (CBT)Dialectical Behaviour Therapy (DBT)Mindfulness-Based Cognitive Therapy (MBCT)Counselling, Family therapy, Referral to External Services: If BrightPath Neuro cannot meet the patient’s needs, the patient will be referred to: CAMHS – For complex mental health cases in children and adolescents. IAPT (Improving Access to Psychological Therapies) – For moderate to severe depression or anxiety. Psychiatric Services – For medication management or psychiatric input.

5.4 Communication with Patients and Caregivers

Transparency: Patients and caregivers will be informed of the referral outcome within 5 working days. If a referral is declined, the reasons for this decision will be explained clearly. Consent and Confidentiality: Consent for referral to external services must be obtained from the patient (or caregiver if applicable).Confidentiality will be maintained unless the patient is at risk of harm.

5.5 Documentation and Record-Keeping

All referrals and signposting decisions must be documented in the patient’s record. Documentation should include: Date and source of referral, Reason for referral, Actions taken and follow-up recommendations, Outcome of the referral process

6. Monitoring and Compliance

The Clinical Lead will monitor referral and signposting activity monthly. The Governance Lead will conduct quarterly audits of referral decisions and documentation.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Initial Assessment and Screening Policy (therapy)

1. Purpose

This policy sets out the procedures and guidelines for conducting initial assessments and screenings for patients referred for therapy and counselling at BrightPath Neuro. Psychological therapy and counselling play a key role in supporting individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. These individuals often experience emotional and psychological difficulties, including anxiety, depression, emotional dysregulation, and low self-esteem. A structured and thorough initial assessment and screening process is essential to: Identify the individual’s psychological and emotional needs. Develop a personalised therapy or counselling plan. Match the individual to the most suitable therapeutic approach. Ensure that therapy or counselling aligns with the individual’s cognitive, emotional, and social needs. Identify any potential risks or barriers to therapy.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for therapy or counselling. All staff involved in conducting therapy assessments and delivering therapy, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Counsellors, Psychotherapists, Occupational Therapists, Mental Health Nurses, It covers: Referral and triage process for therapy and counselling. Initial screening and assessment. Identification of psychological, emotional, and social needs. Matching the patient to the most appropriate therapy or intervention. Developing a personalised therapy or counselling plan.

3. Policy Statement

BrightPath Neuro is committed to: Providing evidence-based, patient-centred psychological therapy and counselling. Ensuring that the initial assessment and screening process is thorough and consistent. Delivering therapy and counselling in a safe and supportive environment. Ensuring that therapists are trained and competent to deliver therapy safely and effectively. Actively involving patients (and caregivers, if applicable) in developing therapy plans. Monitoring therapy outcomes and adjusting treatment plans based on patient progress.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies and mental health treatments. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage Process

Referral Sources: Referrals for therapy and counselling may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., anxiety, depression, trauma)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for therapy or counselling. The patient is emotionally stable and able to engage in therapy. Therapy or counselling is appropriate based on the individual’s cognitive and emotional profile. Rejection of Referral: A referral may be rejected if: The patient requires emergency or crisis-level mental health support. The presenting issue falls outside BrightPath Neuro’s scope of care. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options, including: Local NHS mental health services, Private therapy providers, Crisis services (if appropriate)

5.2 Initial Screening

At BrightPath Neuro, the initial screening process is designed to identify an individual’s psychological and emotional needs, assess their capacity to engage in therapy, and evaluate the level of distress and its impact on daily functioning. The screening also helps to identify any potential barriers to therapy, such as cognitive limitations or environmental challenges, which may influence the choice of intervention. A range of validated tools may be used depending on the individual's age and presentation. These include the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Assessment (GAD-7) for individuals aged 12 and above to screen for depression and anxiety, respectively. The Mood and Feelings Questionnaire (MFQ) is used for those aged 6–18 to assess low mood and emotional distress, while the Strengths and Difficulties Questionnaire (SDQ) supports assessment of emotional and behavioural difficulties in children aged 4–17. For trauma-related symptoms, the Impact of Event Scale – Revised (IES-R) is used from age 12+, and the CORE-OM is applied from age 16+ to measure overall psychological distress and wellbeing. The Adverse Childhood Experiences (ACE) Questionnaire, suitable for all ages, screens for early life trauma and adversity. These tools help ensure a thorough, person-centred understanding of the individual’s mental health needs.

5.3 Clinical Interview

A detailed clinical interview should be conducted to gather information on: Emotional and psychological symptoms, Impact of symptoms on daily functioning, Coping strategies and emotional regulation techniques, Family and social support, Environmental factors (e.g., school, work, home life)The interview should explore: History of mental health issues, History of trauma or significant life events, Previous therapy or treatment and response, Family and social context

5.4 Matching to Appropriate Therapy

Following the clinical interview and screening, the patient should be matched to the most appropriate therapeutic intervention based on: Clinical presentation and diagnosis, Cognitive and emotional capacity, Patient preferences, Previous therapy history, Available Therapies: Cognitive Behavioural Therapy (CBT)Dialectical Behaviour Therapy (DBT)Eye Movement Desensitization and Reprocessing (EMDR)Mindfulness-Based Cognitive Therapy (MBCT)Acceptance and Commitment Therapy (ACT)Psychodynamic Therapy, Solution-Focused Brief Therapy (SFBT)Play Therapy

5.5 Development of a Personalised Therapy Plan

The therapy plan should include: Type of therapy, Frequency and duration of sessions, Short-term and long-term goals, Monitoring and review schedule, Safety plan (if needed)Patient and Caregiver Involvement: The patient (and caregiver, if applicable) should be actively involved in developing the therapy plan. The therapy plan should be explained clearly, including: Expected outcomes, Risks and benefits, Right to withdraw from therapy

5.6 Monitoring and Review

Initial Review: A follow-up review should occur within 4–6 weeks of starting therapy. Ongoing Monitoring: Therapy outcomes should be reviewed at least every 8–12 weeks. Termination of Therapy: Therapy may be terminated when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate.

5.7 Documentation and Record-Keeping

All assessment reports, therapy plans, and clinical notes must be recorded in the patient’s record. Consent forms must be stored securely.

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Informed Consent Policy (therapy)

1. Purpose

This policy sets out the procedures and guidelines for obtaining informed consent for all forms of therapy and counselling delivered at BrightPath Neuro.Therapy and counselling play a key role in supporting individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. Psychological interventions, including Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), Eye Movement Desensitisation and Reprocessing (EMDR), and other forms of psychotherapy, require active participation and collaboration between the patient and therapist.For therapy to be effective, it is essential that the patient (and their caregiver where applicable) understands the nature and goals of therapy, the potential risks and benefits, and their right to refuse or withdraw from treatment. Informed consent ensures that the patient engages in therapy with a clear understanding of the process, expectations, and limitations. The purpose of this policy is to: Ensure that patients and caregivers understand the nature and purpose of therapy. Ensure that patients provide informed consent before engaging in therapy. Promote transparency and trust between the therapist and patient. Establish a structured process for documenting and updating consent. Protect patient autonomy and the right to refuse or withdraw from therapy at any time.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for therapy or counselling. All staff involved in providing or overseeing therapy and counselling, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Dialectical Behavioural Therapists, EMDR Practitioners, Counsellors and Psychotherapists, Mental Health Nurses, It covers: Obtaining consent before initiating therapy. Explaining the nature and goals of therapy. Discussing risks, benefits, and limitations of therapy. Documenting and updating consent. Managing withdrawal from therapy.

3. Policy Statement

BrightPath Neuro is committed to: Ensuring that therapy and counselling are provided only with the patient’s informed consent. Providing patients and caregivers with clear, accurate, and balanced information about therapy options. Respecting the patient’s right to refuse therapy or withdraw from therapy at any time without consequence. Ensuring that therapy is delivered in line with professional and ethical standards. Protecting the confidentiality of patient information during and after therapy.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for the use of psychological therapies and mental health interventions. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health care. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 When Consent is Required

Consent must be obtained: Before initiating any form of therapy or counselling. Before making any significant changes to the therapy plan. If the therapist proposes to use a different therapeutic approach. If the therapy plan includes the involvement of other professionals or agencies. Before recording sessions (if applicable).

5.2 Pre-Therapy Discussion

Before therapy begins, the therapist must discuss the following with the patient (and caregiver if applicable):Purpose of Therapy: The therapist should explain the type of therapy being offered, including: Goals and expected outcomes. Structure and frequency of sessions. Duration of therapy. Patient’s role and level of participation required. Therapeutic Approach: The therapist should describe the proposed therapeutic approach, including: How the therapy works. Techniques and strategies to be used. The patient’s role and level of engagement required. Risks and Benefits: The therapist must explain: Potential benefits (e.g., symptom reduction, improved coping skills).Potential risks (e.g., emotional discomfort, increased distress).Limits of the therapy’s effectiveness. Alternative Options: The therapist should provide information about other treatment options, including: Other forms of therapy. Medication. Self-help strategies. Confidentiality: The therapist must explain the limits of confidentiality, including: If the patient poses a risk to themselves or others. Legal requirements to disclose certain information. Safeguarding and child protection responsibilities. Right to Withdraw: The patient must be informed that they have the right to withdraw from therapy at any time without consequence. Recording of Sessions: If sessions are to be recorded (e.g., for supervision), the patient must consent in writing. Patients have the right to refuse recording without affecting their access to therapy.

5.3 Capacity to Consent

Adult Patients (Over 16): Patients aged 16 or over are presumed to have the capacity to consent unless there is evidence to the contrary. If capacity is in doubt, a capacity assessment should be conducted in line with the Mental Capacity Act 2005.Children and Young People (Under 16):If the patient is under 16, consent should be obtained from a parent or legal guardian unless the patient is assessed as Gillick competent. If a young person under 16 is deemed to have sufficient understanding of therapy, they can consent without parental involvement. Patients Lacking Capacity: If a patient lacks capacity, decisions should be made in their best interests under the Mental Capacity Act.

5.4 Documenting Consent

Consent Forms: The therapist must complete a consent form before initiating therapy. The consent form should include: Type of therapy. Expected goals and outcomes. Risks and benefits of therapy. Alternative treatment options. Right to withdraw from therapy. Limits of confidentiality. Signature of the patient (or caregiver if applicable).Updating Consent: Consent should be reviewed and updated: After significant changes to the therapy plan. If the therapist proposes to use a different therapy model. If the patient’s capacity to consent changes. Record-Keeping: All consent forms should be stored securely in the patient’s health record. If the patient withdraws consent, this should be documented clearly in their record.

5.5 Withdrawal from Therapy

Patient-Initiated Withdrawal: Patients have the right to stop therapy at any time. The therapist should explore the reasons for withdrawal and offer alternative options if appropriate. Therapist-Initiated Withdrawal: Therapy may be terminated if: The patient is not engaging with therapy. Therapy is no longer clinically appropriate. The patient requires a higher level of care than BrightPath Neuro can provide.

6. Monitoring and Compliance

The Clinical Lead will monitor the completion and accuracy of consent documentation. The Governance Lead will conduct quarterly audits of consent records. The Clinical Team will ensure that therapists are trained in obtaining informed consent.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Psychological and Emotional Wellbeing Policy

1. Purpose

This policy sets out the procedures and guidelines for promoting and supporting the psychological and emotional wellbeing of patients at BrightPath Neuro. Psychological and emotional wellbeing are critical components of overall mental health and quality of life. Individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia often experience increased emotional vulnerability, including: Anxiety and depression, Emotional dysregulation, Low self-esteem, Social withdrawal, Challenges in managing everyday stressors, Poor emotional wellbeing can significantly affect academic, social, and occupational functioning. BrightPath Neuro recognises the importance of providing structured and evidence-based psychological support to improve emotional health and enhance coping strategies. The purpose of this policy is to: Establish a structured framework for supporting psychological and emotional wellbeing. Promote emotional resilience and positive coping strategies. Ensure that psychological and emotional needs are identified early and addressed promptly. Provide access to tailored interventions based on individual needs and neurodevelopmental profiles. Foster a safe, supportive, and non-judgmental environment for patients and caregivers.

2. Scope

This policy applies to: All patients at BrightPath Neuro receiving support for psychological or emotional wellbeing. All staff involved in delivering psychological and emotional wellbeing support, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Dialectical Behavioural Therapists, Counsellors and Psychotherapists, Occupational Therapists, Mental Health Nurses, Non-Medical Prescribers (NMPs)It covers: Assessment and identification of psychological and emotional wellbeing issues. Development of Individualised support and intervention plans. Delivery of evidence-based psychological interventions. Promotion of emotional resilience and coping strategies. Communication and collaboration with patients and caregivers. Monitoring and reviewing psychological and emotional wellbeing outcomes.

3. Policy Statement

BrightPath Neuro is committed to: Promoting psychological and emotional wellbeing as an integral part of overall health. Providing patients with access to tailored, evidence-based psychological support. Encouraging self-awareness and emotional resilience. Delivering interventions in a compassionate, trauma-informed, and patient-centred manner. Ensuring that staff are trained and competent in supporting psychological and emotional wellbeing. Monitoring treatment outcomes and adjusting care plans based on patient progress.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies and mental health treatments. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Assessment and Identification of Psychological and Emotional Needs

Referral Sources: Referrals for psychological and emotional wellbeing support may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting emotional and psychological issues (e.g., mood changes, emotional outbursts)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: The symptoms meet the criteria for psychological support. Symptoms are not life-threatening or requiring emergency intervention. The patient agrees to engage in therapy. Rejection of Referral: A referral may be rejected if: The patient requires emergency or crisis-level mental health support. The presenting issue falls outside BrightPath Neuro’s scope of care. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options, including: Local NHS mental health services, Private therapy providers, Crisis services (if appropriate)

5.2 Development of a Personalised Wellbeing Plan

Goals: Therapy and support plans should aim to: Reduce emotional distress and anxiety. Improve emotional regulation. Develop positive coping strategies. Increase emotional awareness and resilience. Plan Components: The personalised wellbeing plan should include: Type of therapy (if applicable).Frequency and duration of sessions. Emotional regulation techniques. Social and peer support. Lifestyle modifications (e.g., sleep, diet, exercise).Safety and crisis management strategies. Patient and Caregiver Involvement: The patient (and caregiver, if applicable) should be

involved in creating the plan. The plan should reflect the patient’s strengths, preferences, and goals.

5.3 Psychological and Emotional Interventions

At BrightPath Neuro, psychological and emotional interventions are tailored to the individual’s emotional profile and grounded in evidence-based practice. A variety of therapeutic approaches are available to address a wide range of emotional and psychological needs. Cognitive Behavioural Therapy (CBT) is used to help individuals identify and change negative thought patterns, making it effective for anxiety, depression, and emotional dysregulation. Dialectical Behaviour Therapy (DBT) focuses on enhancing emotional regulation and distress tolerance, particularly for those with borderline traits or emotional instability. For individuals experiencing trauma, Eye Movement Desensitisation and Reprocessing (EMDR) supports the processing and reduction of trauma-related symptoms, including PTSD and complex trauma. Mindfulness-Based Therapy and Acceptance and Commitment Therapy (ACT) are both beneficial in increasing emotional awareness, reducing stress, and promoting psychological flexibility. Solution-Focused Therapy helps individuals build on their existing strengths and is suitable for those with mild to moderate mental health concerns. Finally, Counselling offers a supportive space for exploring emotional distress, relationship difficulties, and developing effective coping strategies. All interventions are selected based on clinical need, individual preferences, and therapeutic suitability.

5.4 Monitoring and Review

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting the wellbeing plan. Adjustments should be made based on the patient’s feedback and progress. Ongoing Monitoring: Wellbeing plans should be reviewed every 3 months. The review should assess: Changes in emotional wellbeing, Response to psychological interventions, Changes in social or environmental factors, Annual Review: A full review of the wellbeing plan should be conducted annually. Adjustments should be made based on patient response and any changes in mental health status.

5.5 Documentation and Record-Keeping

All wellbeing plans and therapy notes must be documented in the patient’s record. Any changes to the plan should be recorded and signed by the clinician. Consent forms should be stored securely.

6. Monitoring and Compliance

The Clinical Lead will monitor completion rates and patient outcomes. The Governance Lead will conduct quarterly audits of wellbeing plans and therapy records.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

CBT (Cognitive Behavioral Therapy) Policy

1. Purpose

This policy sets out the procedures and guidelines for delivering Cognitive Behavioural Therapy (CBT) at BrightPath Neuro. Cognitive Behavioural Therapy (CBT) is an evidence-based psychological therapy used to treat a range of mental health conditions, including anxiety, depression, emotional dysregulation, and stress-related disorders. CBT focuses on identifying and modifying unhelpful thoughts, beliefs, and behaviours that contribute to emotional and psychological distress. CBT has been shown to be particularly effective for individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia. By helping patients develop healthier thinking patterns and coping strategies, CBT can enhance emotional regulation, improve decision-making, and strengthen interpersonal relationships. The purpose of this policy is to: Establish a structured framework for delivering CBT interventions at BrightPath Neuro. Ensure that CBT is delivered in accordance with professional and clinical standards. Tailor CBT interventions to the individual’s neurodevelopmental profile and psychological needs. Provide a consistent and evidence-based approach to CBT delivery. Ensure that CBT interventions are monitored and adjusted based on patient progress.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for CBT. All staff involved in providing CBT, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Mental Health Nurses, Counsellors and Psychotherapists, Occupational Therapists, Non-Medical Prescribers (NMPs)It covers: Referral and triage for CBT. Delivery of CBT sessions. Monitoring and reviewing CBT outcomes. Termination of CBT treatment. Record-keeping and documentation.

3. Policy Statement

BrightPath Neuro is committed to: Providing CBT as an evidence-based therapeutic intervention for mental health and emotional difficulties. Ensuring that CBT is delivered in a safe, consistent, and patient-centred manner. Tailoring CBT interventions to the individual's cognitive, emotional, and behavioural needs. Encouraging active patient engagement and collaboration during CBT. Monitoring CBT outcomes and adjusting therapy based on patient response and progress. Ensuring that CBT practitioners are appropriately trained and supported.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies, including CBT. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for CBT may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., anxiety, depression, emotional dysregulation)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for CBT intervention. The patient is emotionally stable and able to engage in therapy. CBT is clinically appropriate for the presenting symptoms. Rejection of Referral: A referral may be rejected if: The patient requires crisis or emergency mental health support. The presenting issue falls outside the scope of CBT. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Initial Assessment and Case Formulation

Initial Assessment: A full psychological assessment should be conducted before starting CBT. The assessment should include: Presenting problems and psychological symptoms. Triggers and maintaining factors. Coping strategies and emotional regulation skills. Cognitive patterns and thought distortions. Social and environmental context. Case Formulation: The therapist should develop a CBT case formulation, including: Identification of negative thought patterns and behavioural responses. Link between thoughts, feelings, and behaviours. Treatment goals. Structured treatment plan based on cognitive and behavioural targets.

5.3 Delivery of CBT

At BrightPath Neuro, Cognitive Behavioural Therapy (CBT) is delivered using a structured, goal-oriented approach tailored to the individual's needs. Each session typically follows a consistent format, including setting the agenda, reviewing previous progress and homework, introducing new CBT techniques, engaging in problem-solving and cognitive restructuring, and ending with homework assignments to reinforce learning. Progress is continually monitored against agreed treatment goals. A variety of core CBT techniques may be used, such as cognitive restructuring to identify and challenge unhelpful thoughts, behavioural activation to promote engagement in positive activities, and exposure therapy to help reduce avoidance of feared situations. Other techniques include problem-solving, thought challenging, goal setting, and the use of relaxation and mindfulness strategies to support emotional regulation and reduce distress. CBT is generally delivered in blocks of 6–12 sessions, each lasting 45 to 60 minutes, with frequency (typically weekly) agreed upon in collaboration with the patient. The overall duration of therapy is adjusted based on clinical need, progress, and individual response to treatment.

5.4 Monitoring and Evaluation

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting therapy. The therapist should assess: Patient engagement and participation. Symptom reduction and emotional regulation. Progress toward treatment goals. Ongoing Monitoring: CBT outcomes should be reviewed every 4–6 weeks using validated measures, such as: Patient Health Questionnaire (PHQ-9) – Depression symptoms. Generalized Anxiety Disorder Scale (GAD-7) – Anxiety symptoms. CORE-OM – Psychological wellbeing. Termination of Therapy: CBT may be discontinued when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate. A discharge summary should be provided to the patient.

5.5 Documentation and Record-Keeping

All CBT sessions and treatment plans must be documented in the patient’s health record. The following information should be recorded: Date, time, and content of sessions. Techniques used. Patient response and feedback. Adjustments made to the therapy plan.

6. Monitoring and Compliance

The Clinical Lead will monitor CBT completion rates and patient outcomes. The Governance Lead will conduct quarterly audits of CBT records and outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

DBT (Dialectical Behavioral Therapy) Policy

1. Purpose

This policy sets out the procedures and guidelines for delivering Dialectical Behavioural Therapy (DBT) at BrightPath Neuro. Dialectical Behavioural Therapy (DBT) is an evidence-based psychological therapy designed to treat individuals with emotional dysregulation and impulsive behaviour. DBT combines elements of cognitive-behavioural therapy (CBT) with concepts from mindfulness and acceptance-based approaches. It is particularly effective for individuals with high emotional sensitivity, poor distress tolerance, and difficulty managing interpersonal relationships. DBT has been shown to be effective for individuals with: Borderline Personality Disorder (BPD)Emotional Dysregulation, Self-Harming Behaviours, Suicidal Ideation, Post-Traumatic Stress Disorder (PTSD)Depression and Anxiety, For individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia, DBT can improve emotional regulation, interpersonal effectiveness, and distress tolerance. The purpose of this policy is to: Provide a structured and consistent approach to delivering DBT at BrightPath Neuro. Ensure that DBT is delivered in accordance with professional and clinical standards. Tailor DBT interventions to the individual's neurodevelopmental profile and emotional needs. Ensure that DBT interventions are monitored and adjusted based on patient progress. Empower patients to develop adaptive coping strategies and emotional resilience.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for DBT. All staff involved in providing DBT, including but not limited to: Clinical Psychologists, Dialectical Behavioural Therapists, Mental Health Nurses, Occupational Therapists, Non-Medical Prescribers (NMPs)Counsellors and Psychotherapists, It covers: Referral and triage for DBT. Delivery of DBT sessions. Monitoring and reviewing DBT outcomes. Termination of DBT treatment. Record-keeping and documentation.

3. Policy Statement

BrightPath Neuro is committed to: Providing DBT as an evidence-based intervention for emotional and behavioural difficulties. Delivering DBT in a structured, safe, and patient-centred manner. Tailoring DBT interventions to the individual’s cognitive, emotional, and behavioural needs. Empowering patients to develop emotional resilience and adaptive coping strategies. Monitoring DBT outcomes and adjusting therapy based on patient response and progress. Ensuring that DBT practitioners are appropriately trained and supported.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies, including DBT. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for DBT may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., self-harm, emotional dysregulation)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for DBT intervention. The patient is emotionally stable and able to engage in therapy. DBT is clinically appropriate for the presenting symptoms. Rejection of Referral: A referral may be rejected if: The patient requires crisis or emergency mental health support. The presenting issue falls outside the scope of DBT. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Initial Assessment and Case Formulation

Initial Assessment: A full psychological assessment should be conducted before starting DBT. The assessment should include: Presenting problems and psychological symptoms. Emotional regulation difficulties. Triggers and maintaining factors. Cognitive patterns and thought distortions. Social and environmental context. Case Formulation: The therapist should develop a DBT case formulation, including: Identification of emotional and behavioural targets. Link between thoughts, feelings, and behaviours. Treatment goals. Structured treatment plan based on emotional and behavioural targets.

5.3 Delivery of DBT

Structure of Sessions: DBT should follow a structured format, including: Setting the agenda for each session. Reviewing progress and homework. Introducing new DBT techniques. Problem-solving and emotional regulation. Assigning and reviewing homework. Monitoring progress toward treatment goals. Core Components of DBT: The following DBT modules should be covered: Module, Purpose, Mindfulness, Enhance emotional awareness and present-moment focus, Distress Tolerance, Develop coping strategies for emotional distress, Emotion Regulation, Identify and regulate intense emotional responses, Interpersonal Effectiveness, Improve communication and relationship skills, Techniques Used: The following DBT techniques may be used: Radical acceptance, Opposite action, STOP (Stop, Take a step back, Observe, Proceed)Validation and emotional labelling, Behavioural activation, Cognitive restructuring, Session Frequency and Duration: DBT should be offered in blocks of 12–24 sessions, with each session lasting 45–60 minutes. Sessions should typically be delivered weekly. The duration of DBT should be adjusted based on clinical need and patient progress.

5.4 Monitoring and Evaluation

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting therapy. The therapist should assess: Patient engagement and participation. Symptom reduction and emotional regulation. Progress toward treatment goals. Ongoing Monitoring: DBT outcomes should be reviewed every 4–6 weeks using validated measures, such as: CORE-OM – Overall psychological wellbeing.GAD-7 – Anxiety symptoms.PHQ-9 – Depression symptoms. Termination of Therapy: DBT may be discontinued when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate.

5.5 Documentation and Record-Keeping

All DBT sessions and treatment plans must be documented in the patient’s health record. The following information should be recorded: Date, time, and content of sessions. Techniques used. Patient response and feedback.

6. Monitoring and Compliance

The Clinical Lead will monitor DBT completion rates and patient outcomes. The Governance Lead will conduct quarterly audits of DBT records and outcomes.

7. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

EMDR (Eye Movement Desensitization and Reprocessing) Policy

1. Purpose

This policy sets out the procedures and guidelines for delivering Eye Movement Desensitisation and Reprocessing (EMDR) at BrightPath Neuro. EMDR is an evidence-based psychological therapy designed to help individuals process and reduce distress associated with traumatic memories. It is particularly effective for individuals with Post-Traumatic Stress Disorder (PTSD) and other trauma-related symptoms. EMDR enables individuals to process distressing memories and reduce their emotional impact by using bilateral stimulation, such as guided eye movements or tactile tapping, to promote adaptive processing of traumatic experiences. EMDR is effective in treating: Post-Traumatic Stress Disorder (PTSD)Complex Trauma, Anxiety and Panic Disorders, Depression, Phobias, Emotional Dysregulation, Attachment and Relational Trauma, For individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia, EMDR can reduce emotional distress, improve coping mechanisms, and promote emotional resilience. The purpose of this policy is to: Establish a structured framework for delivering EMDR at BrightPath Neuro. Ensure that EMDR is delivered in accordance with professional and clinical standards. Tailor EMDR interventions to the individual's neurodevelopmental and psychological needs. Provide a consistent and evidence-based approach to EMDR delivery. Monitor EMDR outcomes and adjust therapy based on patient response and progress.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for EMDR. All staff involved in providing EMDR, including but not limited to: Clinical Psychologists, EMDR Practitioners, Counsellors and Psychotherapists, Mental Health Nurses, Occupational Therapists, Non-Medical Prescribers (NMPs)It covers: Referral and triage for EMDR. Delivery of EMDR sessions. Monitoring and reviewing EMDR outcomes. Termination of EMDR treatment. Record-keeping and documentation.

3. Policy Statement

BrightPath Neuro is committed to: Providing EMDR as an evidence-based therapeutic intervention for trauma-related and psychological distress. Ensuring that EMDR is delivered in a safe, structured, and patient-centred manner. Tailoring EMDR interventions to the individual's cognitive, emotional, and behavioural needs. Empowering patients to process and integrate traumatic memories. Monitoring EMDR outcomes and adjusting therapy based on patient response and progress. Ensuring that EMDR practitioners are appropriately trained and supported.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies, including EMDR. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. EMDR UK and Europe Guidelines – Professional standards for the delivery of EMDR therapy. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for EMDR may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., trauma, dissociation, emotional distress)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for EMDR intervention. The patient is emotionally stable and able to engage in therapy. EMDR is clinically appropriate for the presenting symptoms. Rejection of Referral: A referral may be rejected if: The patient requires crisis or emergency mental health support. The presenting issue falls outside the scope of EMDR. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Initial Assessment and Case Formulation

Initial Assessment: A full psychological assessment should be conducted before starting EMDR. The assessment should include: Presenting problems and psychological symptoms. History and nature of trauma. Triggers and maintaining factors. Cognitive patterns and thought distortions. Dissociative symptoms (if present).Social and environmental context. Case Formulation: The therapist should develop an EMDR case formulation, including: Identification of traumatic memories or distressing events .Link between thoughts, feelings, and behaviours. Emotional and cognitive targets for therapy. Structured treatment plan based on emotional and behavioural targets.

5.3 Delivery of EMDR

At BrightPath Neuro, Eye Movement Desensitisation and Reprocessing (EMDR) is delivered using a structured and phased approach, specifically designed to help individuals process and reduce distress related to traumatic memories. Each session follows a clear format, including setting the session agenda, reviewing progress, engaging in guided bilateral stimulation (e.g., eye movements or tapping), processing traumatic memories, applying reintegration and emotional regulation strategies, and monitoring progress towards agreed treatment goals. EMDR is based on the standard eight-phase model, which includes: History Taking – gathering background information and identifying target memories; Preparation – building therapeutic rapport and teaching emotional regulation skills; Assessment – identifying distressing memories and associated thoughts; Desensitisation – using bilateral stimulation to reduce emotional distress; Installation – reinforcing positive beliefs and emotional responses; Body Scan – identifying and resolving any lingering physical symptoms; Closure – ensuring emotional stability at the end of each session; Reevaluation – reviewing progress and updating treatment targets as needed. EMDR is typically offered in blocks of 6–12 sessions, each lasting 60 to 90 minutes, with the frequency (usually weekly) agreed upon collaboratively with the patient. The overall duration is flexible and adjusted according to clinical need, complexity of trauma, and individual progress.

5.4 Monitoring and Evaluation

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting therapy. The therapist should assess: Patient engagement and participation. Symptom reduction and emotional regulation. Progress toward treatment goals. Ongoing Monitoring: EMDR outcomes should be reviewed every 4–6 weeks using validated measures, such as: Impact of Events Scale (IES-R) – Measures trauma-related symptoms.

CORE-OM – Overall psychological wellbeing. Termination of Therapy: EMDR may be discontinued when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate.

5.5 Documentation and Record-Keeping

All EMDR sessions and treatment plans must be documented in the patient’s health record. Records should include: Date, time, and content of sessions. Techniques used. Patient response and feedback.

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

iCBT (Internet-Based CBT) Policy

1. Purpose

This policy sets out the procedures and guidelines for delivering Internet-Based Cognitive Behavioural Therapy (iCBT) at BrightPath Neuro. Internet-Based Cognitive Behavioural Therapy (iCBT) is an evidence-based psychological therapy delivered online through secure digital platforms. It follows the same principles as Cognitive Behavioural Therapy (CBT) but is conducted remotely using interactive modules, real-time messaging, video calls, and digital exercises. iCBT is designed to: Provide greater flexibility and accessibility for patients who may face barriers to attending face-to-face sessions. Offer structured and evidence-based psychological support in a secure and confidential online environment. Enable patients to work through therapeutic modules at their own pace while maintaining therapist guidance and support. Support patients with mild to moderate symptoms of anxiety, depression, emotional dysregulation, and stress. iCBT is particularly beneficial for individuals with: Anxiety disorders (e.g., generalised anxiety disorder, panic disorder)Depression, Stress and adjustment disorders, Emotional dysregulation, Phobias, Obsessive-Compulsive Disorder (OCD)Low self-esteem, The purpose of this policy is to: Establish a structured and consistent approach to delivering iCBT at BrightPath Neuro. Ensure that iCBT is delivered in accordance with professional and clinical standards. Ensure the confidentiality and security of patient information within an online setting. Tailor iCBT interventions to the individual's cognitive, emotional, and behavioural needs. Provide patients with clear guidance on how to access and engage with iCBT. Monitor patient progress and adjust therapy as needed.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for iCBT. All staff involved in providing or managing iCBT, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Counsellors and Psychotherapists, Mental Health Nurses, Non-Medical Prescribers (NMPs)Occupational Therapists, It covers: Referral and triage for iCBT. Delivery of iCBT sessions. Monitoring and reviewing iCBT outcomes. Termination of iCBT treatment. Data protection and online security. Record-keeping and documentation.

3. Policy Statement

BrightPath Neuro is committed to: Providing iCBT as an evidence-based therapeutic intervention for mild to moderate mental health difficulties. Delivering iCBT in a structured, secure, and patient-centred manner. Ensuring that iCBT is adapted to the individual’s cognitive and emotional profile. Encouraging patient autonomy and flexibility within a structured therapeutic framework. Monitoring iCBT outcomes and adjusting therapy based on patient response and progress. Ensuring that iCBT platforms meet national standards for online security and data protection.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies, including iCBT. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data. ISO 27001 – International standard for information security management systems.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for iCBT may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., anxiety, depression, stress)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for iCBT intervention. The patient has access to the required technology (e.g., internet connection, computer).iCBT is clinically appropriate for the presenting symptoms. Rejection of Referral: A referral may be rejected if: The patient requires crisis or emergency mental health support. The presenting issue falls outside the scope of iCBT. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Initial Assessment and Setup

Technical Requirements: Patients should be provided with guidance on the technical requirements for iCBT, including: Internet connection and device compatibility. Secure login process and data protection standards. Confidentiality of online communication. Initial Assessment: A full psychological assessment should be conducted before starting iCBT. The assessment should include: Presenting problems and psychological symptoms. Cognitive patterns and thought distortions. Emotional and behavioural responses. Environmental and social context. Consent: Written consent must be obtained before starting iCBT. Consent must include an agreement to participate in therapy and understanding of the data security measures.

5.3 Delivery of iCBT

At BrightPath Neuro, internet-based Cognitive Behavioural Therapy (iCBT) is delivered through a structured digital programme, combining evidence-based techniques with flexible access. The course typically includes an introductory module to explain how iCBT works, followed by targeted modules on cognitive restructuring, behavioural activation, emotional regulation, and relapse prevention. The programme is designed to be interactive and user-friendly, enabling individuals to engage at their own pace while building key psychological skills. Core CBT techniques used in iCBT include cognitive restructuring to identify and modify negative thought patterns, behavioural activation to promote engagement in enjoyable and meaningful activities, and problem-solving strategies to manage real-life challenges. Additional modules may incorporate relaxation and mindfulness to support emotional regulation, as well as goal setting to help maintain motivation and structure. iCBT is typically delivered over a period of 8 to 12 weeks, with patients encouraged to engage with the content 1–2 times per week. To support progress and ensure a personalised approach, real-time therapist feedback is available through secure messaging or video calls, providing guidance, encouragement, and clinical oversight throughout the intervention.

5.4 Monitoring and Evaluation

Patient Engagement: Patient engagement should be monitored weekly. If a patient fails to engage with the platform for 2 consecutive weeks, follow-up contact should be made. Clinical Progress: Outcomes should be measured using validated scales: PHQ-9 – Depression symptomsGAD-7 – Anxiety symptoms, CORE-OM – Psychological wellbeing5.5 Data Protection and Security, The iCBT platform must comply with: ISO 27001 standards for data security.UK GDPR for confidentiality and data storage.

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

ACT (Acceptance and Commitment Therapy) Policy

1. Purpose

This policy sets out the procedures and guidelines for delivering Acceptance and Commitment Therapy (ACT) at BrightPath Neuro. Acceptance and Commitment Therapy (ACT) is an evidence-based psychological intervention that combines principles of mindfulness, acceptance, and behaviour change. ACT helps individuals develop psychological flexibility by encouraging them to: Accept difficult thoughts and emotions rather than trying to eliminate them. Identify their values and commit to actions aligned with those values. Develop mindfulness and emotional regulation skills to cope with distress. ACT has been shown to be effective for individuals with: Anxiety disorders (e.g., generalised anxiety disorder, social anxiety)Depression, Emotional Dysregulation, Obsessive-Compulsive Disorder (OCD)Post-Traumatic Stress Disorder (PTSD)Stress and Adjustment Disorders, Low Self-Esteem, Chronic Pain, Psychosis, ACT is particularly effective for individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia, as it supports emotional resilience, improves coping strategies, and enhances self-regulation. The purpose of this policy is to: Establish a structured and evidence-based framework for delivering ACT at BrightPath Neuro. Ensure that ACT is tailored to the individual’s cognitive, emotional, and behavioural needs. Ensure that ACT interventions are delivered in accordance with professional and clinical standards. Encourage patients to engage in meaningful behaviour change aligned with their values. Monitor ACT outcomes and adjust therapy based on patient response and progress.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for ACT. All staff involved in providing ACT, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Counsellors and Psychotherapists, Mental Health Nurses, Occupational Therapists, Non-Medical Prescribers (NMPs)It covers: Referral and triage for ACT. Delivery of ACT sessions. Monitoring and reviewing ACT outcomes. Termination of ACT treatment. Record-keeping and documentation.

3. Policy Statement

BrightPath Neuro is committed to: Providing ACT as an evidence-based therapeutic intervention for mental health difficulties. Delivering ACT in a structured, safe, and patient-centred manner. Ensuring that ACT is tailored to the individual’s neurodevelopmental and psychological profile. Encouraging patients to develop emotional resilience and psychological flexibility. Monitoring ACT outcomes and adjusting therapy based on patient response and progress. Ensuring that ACT practitioners are appropriately trained and supported.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies, including ACT. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for ACT may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., anxiety, depression, emotional dysregulation)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for ACT intervention. The patient is emotionally stable and able to engage in therapy. ACT is clinically appropriate for the presenting symptoms. Rejection of Referral: A referral may be rejected if: The patient requires crisis or emergency mental health support. The presenting issue falls outside the scope of ACT. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Initial Assessment and Case Formulation

Initial Assessment: A full psychological assessment should be conducted before starting ACT. The assessment should include: Presenting problems and psychological symptoms. Emotional and behavioural responses. Cognitive patterns and thought distortions. Values and life goals. Social and environmental context. Case Formulation: The therapist should develop an ACT case formulation, including: Identification of psychological barriers to change. Emotional and cognitive targets for therapy. Link between thoughts, feelings, and behaviours. Treatment goals aligned with patient’s values.

5.3 Delivery of ACT

At BrightPath Neuro, Acceptance and Commitment Therapy (ACT) is delivered using a structured, values-driven approach aimed at enhancing psychological flexibility and promoting meaningful change. Each session follows a consistent format, including setting the agenda, reviewing progress and barriers, introducing new ACT techniques, practicing cognitive diffusion and acceptance exercises, and engaging in value-based goal setting and action planning. Progress is regularly monitored in line with the individual’s treatment goals. ACT is centred around six core components: Acceptance – promoting openness to difficult emotions rather than avoiding them; Cognitive Diffusion – helping individuals change how they relate to unhelpful thoughts; Mindfulness – fostering present-moment awareness and emotional grounding; Self-as-Context – building a sense of the observing self, separate from experiences; Values – identifying what matters most to the individual; Committed Action – taking purposeful steps aligned with personal values. A range of techniques is used to support these components, including mindfulness meditation, thought labelling and diffusion, values clarification exercises, behavioural activation, imagery and visualisation, and acceptance of discomfort as part of growth. ACT is typically delivered over 8–12 sessions, with each session lasting 45 to 60 minutes, and is usually conducted on a weekly basis. The structure and content may be adapted based on clinical need and individual engagement, ensuring the therapy remains both relevant and impactful.

5.4 Monitoring and Evaluation

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting therapy. The therapist should assess: Patient engagement and participation. Symptom reduction and emotional regulation. Progress toward treatment goals. Ongoing Monitoring: ACT outcomes should be reviewed every 4–6 weeks using validated scales: CORE-OM – Overall psychological wellbeing.PHQ-9 – Depression symptoms.GAD-7 – Anxiety symptoms.

5.5 Termination of Therapy

ACT may be discontinued when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate.

5.6 Documentation and Record-Keeping

All ACT sessions and treatment plans must be documented in the patient’s health record. Records should include: Date, time, and content of sessions, Techniques used, Patient response and feedback.

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Solution-Focused Therapy (SFT) Policy

1.Purpose

This policy sets out the procedures and guidelines for delivering Solution-Focused Therapy (SFT) at BrightPath Neuro. Solution-Focused Therapy (SFT) is a goal-directed and future-focused therapeutic approach that helps individuals identify and develop solutions to their problems rather than focusing on the causes of distress. SFT aims to build on existing strengths and resources to promote positive change and resilience. Unlike traditional therapies that explore past experiences and root causes, SFT focuses on: Identifying the patient’s strengths and coping strategies. Developing clear and achievable goals. Encouraging small, incremental changes that lead to broader improvement. Empowering patients to use their existing skills and resources to solve problems. SFT is particularly effective for individuals experiencing: Mild to moderate anxiety, Depression, Emotional Dysregulation, Stress and Adjustment Disorders, Social and Interpersonal Difficulties, Low Self-Esteem, Trauma-Related Symptoms, For individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia, SFT provides a structured and strengths-based approach to improving emotional regulation and enhancing problem-solving skills. The purpose of this policy is to: Establish a structured and evidence-based framework for delivering SFT at BrightPath Neuro. Ensure that SFT is tailored to the individual’s cognitive, emotional, and behavioural needs. Provide a consistent and patient-centred approach to problem-solving and goal-setting. Encourage positive behavioural change by focusing on solutions rather than problems. Monitor SFT outcomes and adjust therapy based on patient response and progress.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for SFT. All staff involved in providing SFT, including but not limited to: Clinical Psychologists, Cognitive Behavioural Therapists, Counsellors and Psychotherapists, Mental Health Nurses, Occupational Therapists, Non-Medical Prescribers (NMPs)It covers: Referral and triage for SFT. Delivery of SFT sessions. Monitoring and reviewing SFT outcomes. Termination of SFT treatment. Record-keeping and documentation.

3. Policy Statement

BrightPath Neuro is committed to: Providing SFT as an evidence-based therapeutic intervention for mental health difficulties. Delivering SFT in a structured, solution-focused, and patient-centred manner. Empowering patients to identify their strengths and develop practical solutions. Encouraging small, meaningful changes that promote emotional and psychological resilience. Monitoring SFT outcomes and adjusting therapy based on patient response and progress. Ensuring that SFT practitioners are appropriately trained and supported.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies, including SFT. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for SFT may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., anxiety, depression, emotional dysregulation)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for SFT intervention. The patient is emotionally stable and able to engage in therapy. SFT is clinically appropriate for the presenting symptoms. Rejection of Referral: A referral may be rejected if: The patient requires crisis or emergency mental health support. The presenting issue falls outside the scope of SFT. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Initial Assessment and Case Formulation

Initial Assessment: A full psychological assessment should be conducted before starting SFT. The assessment should include: Presenting problems and psychological symptoms. Emotional and behavioural responses. Cognitive patterns and thought distortions. Environmental and social context. Strengths, skills, and resources. Case Formulation: The therapist should develop an SFT case formulation, including: Identification of the problem. Identification of existing strengths and resources. Goal setting aligned with patient’s values. Practical steps toward achieving positive outcomes.

5.3 Delivery of SFT

At BrightPath Neuro, Solution-Focused Therapy (SFT) is delivered using a goal-oriented and strengths-based approach, designed to empower individuals to find practical solutions and build on their existing capabilities. Each session follows a structured format, beginning with establishing a clear goal, exploring the individual's strengths and past successes, and identifying realistic steps toward achieving their objectives. The process encourages small, manageable changes, with regular monitoring of progress and celebration of positive outcomes to reinforce motivation. A variety of key SFT techniques are used, including the Miracle Question, which helps individuals visualise a preferred future; Scaling Questions to measure progress, motivation, or confidence; Exception Questions to highlight times when the problem was less present; Coping Questions to explore effective strategies the individual has already used; Strengths Identification to boost confidence; and positive feedback to encourage ongoing progress. SFT is typically delivered over 6 to 12 sessions, each lasting 45–60 minutes, and is usually conducted on a weekly basis. The approach is collaborative, forward-focused, and tailored to the individual's pace, promoting rapid yet sustainable improvements in emotional wellbeing.

5.4 Monitoring and Evaluation

Initial Review: A follow-up review should be conducted within 4–6 weeks of starting therapy. The therapist should assess: Patient engagement and participation. Progress toward achieving goals. Emotional regulation and behavioural changes. Ongoing Monitoring: SFT outcomes should be reviewed every 4–6 weeks using validated scales: CORE-OM – Overall psychological wellbeing.PHQ-9 – Depression symptoms.GAD-7 – Anxiety symptoms.

5.5 Termination of Therapy

SFT may be discontinued when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate.

5.6 Documentation and Record-Keeping

All SFT sessions and treatment plans must be documented in the patient’s health record. Records should include: Date, time, and content of sessions. Techniques used. Patient response and feedback.

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Hypnotherapy Policy

1. Purpose

This policy sets out the procedures and guidelines for delivering Hypnotherapy at BrightPath Neuro. Hypnotherapy is a complementary therapeutic approach that uses guided relaxation, focused attention, and suggestion techniques to promote a heightened state of awareness and openness to positive behavioural change. In this state, the patient is more receptive to suggestions and cognitive reframing, which can help address a range of psychological, emotional, and behavioural issues. Hypnotherapy can be used as a standalone therapy or alongside other psychological therapies such as Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), and Acceptance and Commitment Therapy (ACT).Hypnotherapy has been shown to be effective for treating: Anxiety (e.g., generalised anxiety, phobias, performance anxiety)Depression, Emotional Dysregulation, Stress and Adjustment Disorders, Sleep Disturbances (e.g., insomnia, night terrors)Post-Traumatic Stress Disorder (PTSD)Obsessive-Compulsive Disorder (OCD)Pain Management, Smoking Cessation and Substance Use, Weight Management, Hypnotherapy is particularly effective for individuals with neurodevelopmental conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Condition (ASC), and dyslexia as it helps promote emotional regulation, stress reduction, and improved focus and concentration. The purpose of this policy is to: Establish a structured and consistent approach to delivering hypnotherapy at BrightPath Neuro. Ensure that hypnotherapy is delivered in accordance with professional and clinical standards. Tailor hypnotherapy interventions to the individual’s cognitive, emotional, and behavioural needs. Ensure that hypnotherapy is offered as part of a comprehensive, multi-modal treatment plan. Monitor hypnotherapy outcomes and adjust therapy based on patient response and progress.

2. Scope

This policy applies to: All patients referred to BrightPath Neuro for hypnotherapy. All staff involved in providing or managing hypnotherapy, including but not limited to: Clinical Psychologists, Hypnotherapists, Cognitive Behavioural Therapists, Counsellors and Psychotherapists, Occupational Therapists, Mental Health Nurses, Non-Medical Prescribers (NMPs)It covers: Referral and triage for hypnotherapy. Delivery of hypnotherapy sessions. Monitoring and reviewing hypnotherapy outcomes. Termination of hypnotherapy treatment. Record-keeping and documentation.

3. Policy Statement

BrightPath Neuro is committed to: Providing hypnotherapy as an evidence-based complementary intervention for mental health and behavioural difficulties. Ensuring that hypnotherapy is delivered in a structured, consistent, and patient-centred manner. Delivering hypnotherapy in a safe and professional environment. Empowering patients to develop coping strategies and promote positive change through hypnotherapy. Monitoring hypnotherapy outcomes and adjusting therapy based on patient response and progress. Ensuring that hypnotherapists are appropriately trained and supported.

4. Legal and Regulatory Framework

This policy aligns with the following legislation and guidelines: Mental Health Act 1983 (Amended 2007) – Establishes guidelines for assessing and managing mental health conditions. Mental Capacity Act 2005 – Provides guidance on decision-making for individuals lacking capacity. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014National Institute for Health and Care Excellence (NICE) Guidelines – Recommendations for psychological therapies, including hypnotherapy. British Psychological Society (BPS) Guidelines – Professional standards for psychological practice. British Society of Clinical and Academic Hypnosis (BSCAH) Guidelines – Professional standards for hypnotherapy. General Medical Council (GMC) Guidelines – Professional standards for mental health care. Care Quality Commission (CQC) Regulations – Establishes standards for healthcare services. Data Protection Act 2018 (UK GDPR) – Governs the collection, storage, and processing of personal and sensitive data.

5. Procedure

5.1 Referral and Triage

Referral Sources: Referrals for hypnotherapy may come from: General Practitioners (GP)Schools, educational psychologists, or SENCOs, Mental health services (e.g., CAMHS)Social care services, Self-referral (if aged 18 or older)Caregivers (for children or dependent adults)Initial Review of Referral: The referral must be reviewed within 5 working days by the Clinical Lead or a senior clinician. The following information should be included in the referral: Presenting psychological and emotional issues (e.g., anxiety, emotional dysregulation)Relevant medical and psychiatric history, Current medication and known side effects, Family and social context, History of trauma or significant life events, Acceptance of Referral: The referral will be accepted if: Symptoms meet the criteria for hypnotherapy intervention. The patient is emotionally stable and able to engage in therapy. Hypnotherapy is clinically appropriate for the presenting symptoms. Rejection of Referral: A referral may be rejected if: The patient requires crisis or emergency mental health support. The presenting issue falls outside the scope of hypnotherapy. The patient refuses to engage in the therapy process. If a referral is rejected, the patient will be advised of alternative options.

5.2 Initial Assessment and Case Formulation

Initial Assessment: A full psychological assessment should be conducted before starting hypnotherapy. The assessment should include: Presenting problems and psychological symptoms. Emotional and behavioural responses. Cognitive patterns and thought distortions. Environmental and social context. Strengths and coping strategies. Case Formulation: The therapist should develop a hypnotherapy case formulation, including: Identification of specific therapeutic targets. Cognitive and emotional patterns to be addressed. Techniques to be used during hypnotherapy. Monitoring and evaluation plan.

5.3 Delivery of Hypnotherapy

At BrightPath Neuro, hypnotherapy is delivered using a structured, therapeutic approach that combines deep relaxation with focused mental engagement to support psychological and emotional healing. Each session begins with establishing a clear goal, followed by the induction of a relaxed, focused state. During this state, the clinician introduces positive suggestions aligned with the individual’s therapeutic goals and facilitates cognitive and emotional reprocessing. Sessions conclude with grounding and reintegration to ensure the patient returns to a calm and stable state. A range of hypnotherapy techniques may be used, including relaxation induction to reduce physiological arousal, positive suggestion to promote adaptive thinking, and guided imagery to support emotional processing. Age regression may be used to explore and reframe past trauma, while cognitive reframing helps shift maladaptive thought patterns. The technique of anchoring can be used to establish and reinforce positive emotional states for future use. Hypnotherapy is typically delivered over 6 to 12 sessions, each lasting 45 to 60 minutes, with sessions usually held on a weekly basis. The approach is always tailored to the individual's goals, readiness, and therapeutic needs, and is used as part of an integrated care plan.

5.4 Monitoring and Evaluation

Hypnotherapy outcomes should be reviewed using: CORE-OM – Psychological wellbeing.PHQ-9 – Depression symptoms.GAD-7 – Anxiety symptoms. IES-R – Trauma-related symptoms.

5.5 Termination of Therapy

Hypnotherapy may be discontinued when: Goals have been met. The patient chooses to withdraw from therapy. Therapy is no longer clinically appropriate.5.6 Documentation and Record-Keeping, All hypnotherapy sessions and treatment plans must be documented in the patient’s health record.

6. Review

This policy will be reviewed annually or sooner if regulatory changes occur.

Diagnosis Appeal Policy

1. Introduction At Brightpath Neuro, we aim to provide accurate and evidence-based diagnostic services for neurodiversity and mental health conditions. We understand that clients may wish to seek clarification or challenge the outcome of a diagnosis if they feel it is inaccurate or incomplete. This policy outlines the process for appealing a diagnosis or assessment outcome, ensuring that all concerns are addressed fairly, professionally, and in line with clinical and professional standards.

👉 Submit an Appeal

2. Scope This policy applies to all diagnostic assessments provided by Brightpath Neuro, including but not limited to: ADHD Assessments Autism (ASC) Assessments Dyslexia Assessments Sleep Assessments Weight Management and Mood Assessments It applies to all clients who have undergone a formal assessment and received a written report or diagnosis.

3. Grounds for Appeal You may request a review or appeal of a diagnosis if you believe that: The assessment process was incomplete or not carried out according to professional guidelines. Relevant clinical information was not considered during the assessment. The diagnostic criteria were misapplied. There was a factual or clerical error in the report. You have obtained new evidence that was not available during the original assessment.

4. Appeal Process

Step 1 – Informal Resolution Before submitting a formal appeal, we encourage you to contact Brightpath Neuro to discuss your concerns with the clinician who conducted the assessment. You must raise your concerns within 14 calendar days of receiving the diagnosis or report. The clinician will review the assessment details and attempt to resolve any misunderstandings or provide further clarification. If you remain dissatisfied, you may proceed to a formal appeal.

Step 2 – Formal Appeal Submission To submit a formal appeal, you must send a written request to Brightpath Neuro within 28 calendar days of receiving the diagnosis or report. Your written request must include: Your full name and contact details. The date and type of assessment. A detailed explanation of why you believe the diagnosis is inaccurate or incomplete. Any supporting evidence (e.g., medical reports, third-party assessments). Submit your appeal to: Email: [email protected]

Step 3 – Appeal Review Upon receiving your appeal, the following process will apply: Initial Acknowledgement: We will acknowledge receipt of your appeal within 2 working days. Independent Review: An independent clinician (not involved in the original assessment) will be appointed to review the case. The review will assess: Whether the correct diagnostic procedures were followed. Whether all relevant information was considered. Whether the conclusions reached were reasonable based on the evidence provided. Decision and Outcome: The review will be completed within 14 calendar days of receiving the appeal. You will receive a written response detailing the outcome, which may include: Confirmation that the original diagnosis was accurate. A revised diagnosis based on additional evidence or clinical review. An offer to conduct a further assessment (at no additional cost).

Step 4 – Further Action If you remain dissatisfied with the outcome of the appeal, you may: Request a second independent opinion from a different clinician (subject to availability). Refer the matter to the Director of Clinical Services for a final review. Seek external resolution through the relevant regulatory bodies, including: Care Quality Commission (CQC): Website: www.cqc.org.uk Phone: 03000 616161 Professional Body for Registered Clinicians: British Psychological Society (BPS) Nursing and Midwifery Council (NMC)

5. Outcomes and Resolutions Following the outcome of the appeal, Brightpath Neuro may: Amend the diagnosis and update the report (if the appeal is upheld). Offer a follow-up assessment at no additional cost (if new evidence is presented). Provide further support or recommendations based on the review outcome. Maintain the original diagnosis if the appeal is not supported by clinical evidence.

6. Confidentiality and Data Protection All appeal information will be treated as confidential and handled in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018. Only staff directly involved in the review process will have access to appeal information.

7. Time Limits Appeals must be submitted within 28 calendar days of receiving the diagnosis or report. Appeals submitted after this period will only be considered under exceptional circumstances (e.g., medical emergencies).

8. Limitations This policy does not cover: Disagreements with professional opinions if the correct process was followed and the diagnosis was clinically justified. Situations where the client has failed to provide full or accurate information during the assessment process. Requests to alter a diagnosis solely for the purpose of accessing benefits or accommodations.

9. Complaints If you wish to make a complaint about the appeals process or the handling of your case, you may follow our Complaints Policy (available on our website or upon request).

10. Monitoring and Review All appeals will be logged and monitored to identify trends and improve the quality of our services. This policy will be reviewed annually or in response to regulatory changes.