Gender Plus Hormone Clinic Also known as Gender Plus Healthcare Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The leaders had put into place a positive and proactive culture of safety-based openness and honesty. Concerns about safety were fully investigated. The manager's ensured lessons were learnt to identify and embed good practices. There was a very positive learning culture with staff managing incidents and safeguarding patients well. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. They managed prescriptions safely. There were processes in place to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe.

This service scored 84 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a culture where patients could see improvements. They had ‘you said, we did’ feedback within the information displayed in the waiting area. This showed clear changes and learning following patient feedback.

Patients experienced care based on the latest updates and learning which followed national updates and safety incidents. Staff raised concerns and were encouraged to report incidents by their managers. They had reported 1 incident since the clinic had opened in January 2024. There was a positive culture for incident reporting and learning and staff were all aware of changes made following the reported incident and what and how to report an incident.

The service had a clear policy for significant events and incident management. The incident reported was discussed in a team meeting and this was part of the process. Where learning was required, there were processes to follow for staff to ensure this was shared and embedded. There were measures in place to keep patients safe. Staff were aware of the duty of candour, but no serious incidents had occurred where it needed to be used.

Patients told us they had a good experience of transitioning between Gender Plus and GPHC. One patient told us they had needed further psychological support whilst they were having hormone treatment, and they accessed this easily and it was included in the cost of their subscription. Other patients told us “Everything feels very joined up and focussed on the goal of delivering the best and safest outcomes for me” and “they have signposted me to online resources of which GPs do shared care and made me aware of alternatives. It is really nice to go to a clinic where they are just so caring and understanding.”

The service shared information about patients’ treatment appropriately with relevant healthcare professionals, such as their GP. The service asked GPs for a shared care agreement and if agreed, this meant the patient experienced a joined-up approach of the management of their treatment. Staff ensured continuity of care when patients moved through the different services. The service worked alongside their linked clinic, Gender Plus which was a gender healthcare and education service. They provided psychological support to patients. The staff had joint meetings discussing patients, safeguarding and governance within both Gender Plus and Gender Plus Hormone Clinic (GPHC). All patients who were seen at GPHC had undergone psychological assessments within the Gender Plus clinic. A multidisciplinary (MDT) meeting took place for each patient with the nurse consultant at GPHC, psychologists at Gender Plus and an independent paediatric psychiatrist. They decided together whether patients were suitable for treatment within the hormone clinic.

Staff at Gender Plus told us there was a clear referral pathway into GPHC and they worked well together as a team. We observed a multidisciplinary team meeting where 3 patients were discussed by the psychologists within the Gender Plus clinic for potential hormone treatment. This was detailed and comprehensive. Gender Plus staff told us they had a good relationship with GPHC staff. They were able to refer patients to the service easily without a long wait and felt the process was safe. Staff told us the team at GPHC were professional and thorough and they felt they continuously learned together as a team. Patients were also able to access therapeutic sessions whilst continuing with GPHC for further reflection or exploration at any point of the process.

There was a standard operating procedure (SOP) for GPHC. It detailed the endocrine processes within the clinic including the referral process. A referral into the GPHC did not mean medical treatment would be permitted. The clinic referral criteria was in line with NHS England (NHSE) inclusion and exclusion criteria set out in the Prescribing of Gender Affirming Hormones as part of the Children and Young People’s Gender Service policy, March 2024. All patients were discussed in an MDT meeting prior to being accepted for a consultation for hormone treatment. All referrals for the GPHC needed to include a comprehensive gender assessment report, a completed referral form containing a diagnosis of gender dysphoria and/or incongruence and a care plan, which recommended medical interventions. There was a Patient Safety and Care Policy which outlined the approach to ensuring physical, emotional, and psychological well-being of all patients. There was a SOP for the transfer of care from another provider to GPHC. There was a referral pathway for patients to external services.

All patients we spoke to felt the staff understood their needs. We spoke to a patient they told us staff had ensured they were safe and asked appropriate questions.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. All staff, including non-clinical staff, were trained to level 3 safeguarding adults and children. The safeguarding lead for the service was trained to level 5. The manager told us safeguarding as very important to them and therefore made it a standing agenda item for the team meeting which occurred every 2 weeks. We listened to a team meeting and heard in depth discussions about safeguarding and multidisciplinary team responses. It was evident the team worked well together to protect the patients. Staff understood the Mental Capacity Act 2005 (MCA) and all staff had up to date training on this. The staff referred to the MCA when discussing consent for children aged 16 to 18 and knew how to assess their capacity to make decisions. We observed a consultation for a 16-year-old, alongside their parent or guardian, and consent was clear and patients understanding was checked. The clinic ensured the patient signed the consent form alongside their parent or guardian. They told us that whilst this was not needed as the patient was over 16 years of age, they always obtained a parent’s or guardian signature as well.

We observed consultations between the nurse consultant, patient, their family and the mental health nurse. The nurse consultant respectfully spoke to the patient about any history of abuse and asked if they felt safe. We observed the mental health nurse and nurse consultant discussing safeguarding of the patients and any additional information to be aware of prior to their appointment. They gave patients time alone to speak where needed in a safe space.

The clinic had a clear safeguarding policy and pathway which was up-to-date and accessible to staff. Staff all knew who the safeguarding lead was for advice. Where safeguarding was discussed for a patient or if there were concerns, this was highlighted by a red tab on the patient record. Safeguarding cases were discussed, and outcomes documented as a team, alongside the safeguarding lead, to ensure all patients were safeguarded appropriately. We looked at 4 safeguarding discussions and found the discussions in depth and involving appropriate team members and actions taken were appropriate. There was a Looked After Children’s policy, which included identifying an individual who had responsibility for the child to be involved in the consent and MDT meeting process. The provider stated that best practice would be to involve an individual with appropriate assent of parent responsibility but, where this was not possible, they would document any decision-making regarding the young person’s care and treatment pathways. The service completed a quarterly safeguarding audit. We saw 20 records were reviewed between January and March 2024. They had all been presented at the MDT meeting and potential risks identified.

All patients and families we spoke with told us they were informed about the risks of the hormone treatment in detail. We were told staff took time to go over all the risks and consent form with them prior to signing. One patient told us “Information was given related to all aspects of the treatments, both benefits and risks but the ‘myth-busting’ information was really useful about other areas of the treatment (for example, effect on hair growth/loss) as there is much contradictory information about this online.” Another patient told us “I was told it was up to me to book the first injection appointment, and decide when this would be, and I was encouraged to take the time to think about it and come back when I was sure.” All patients felt they were given time to make decisions and felt well informed. Another patient told us “There has been a strong emphasis on my health throughout the process including pre-treatment blood and health checks and an on-going monitoring of these. I was also reassured that although the hormone blocker injections will be every 6 months, the first one was only for 3 months so we could see how I adjusted to it and would be seen again and assessed before moving to 6 monthly treatments.”

The service worked with patients and their families to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive. All patients underwent psychological assessments prior to being accepted at GPHC. These were undertaken by Gender Plus psychologists; this clinic was linked to GPHC. They presented appropriate patients at an MDT referral meeting. All patients, including those over the age of 18, had their case presented at a referral meeting prior to being accepted for care at the GPHC. This was better than the national guidance which required only patients under the age of 18 to be discussed. All patients required a gender assessment report, referral form containing a diagnosis of gender dysphoria, a care plan which recommended medical interventions, and a signed consent form for the referral to GPHC. All patients were discussed at this referral meeting prior to starting hormone treatment. Where patients were between age 16 and 18 years, there was an independent child and adolescent psychiatrist present; this was in line with best practice. It was mandatory for the nurse consultant to review the GP summary and patients’ blood results prior to booking their initial appointment. All patients who started hormone therapy had physical and mental health checks. As a minimum, they had a check-up at 6 months; this was adjusted as needed. There was a mental health nurse present at every appointment within the clinic. Patients were able to attend a mental health session if required and were supported throughout their treatment. All patients who had complex mental health needs had a plan in place from Gender Plus. The nurse discussed fertility as part of the initial consultation and consent process to ensure patients understood the risks and how their fertility would be affected. They signposted patients to next steps and held off hormone treatment until the patient had made a choice about preserv

Staff followed internal policies and operating procedures which were based on best practice guidance when assessing and treating patients. Assessments were detailed and covered all aspects of risk to ensure patients received the appropriate treatment and support. There was an inclusion criteria for a referral for a 16 to 18-year-old which was in line with the NHSE inclusion/exclusion criteria set out in the Prescribing of Gender Affirming Hormones (masculinising and feminising hormones) as part of the Children and Young People’s Gender Service Policy, March 2024. The consultation was comprehensive and ensured all physical and mental health aspects were discussed and the patient was fully informed of all risks to the hormone treatment including irreversible body changes, change in sexual function and fertility. There was a detransition pathway in place for patients who did not want to continue their treatment; it was in line with national guidance. The service offered was holistic and ensured the patient was supported both medically and mentally. Where clinically indicated appointments were available with the nurse, mental health nurse or psychologists and this was included in the subscriptions costs for GPHC.

All patients and families we spoke to felt the clinic environment was good and appropriate. One parent told us that there was a good atmosphere and a ‘cool environment for the patients.’

Staff had access to appropriate equipment to enable them to complete their role. Equipment was maintained to ensure the patients were kept safe. The service had suitable facilities to meet the needs of patients. There was basic resuscitation equipment available if required. Staff did not lone work and used the facilities provided by the landlord to ensure patients and their families were safe when using the building.

The design of the environment was appropriate for the care they were giving. If patients did not want to wait in the waiting room with others, there was a separate quiet space with a comfortable sofa for them to wait. All windows had one-way visibility, so individuals could look out and have access to light but those outside of the premises could not see inside the location. All equipment we looked at was in date and checked regularly. We found 2 flammable items which were not kept in a metal cupboard in line with Control of Substances Hazardous to Health Regulations 2002. We fed this back to the provider who immediately purchased a metal cabinet to safely store these items.

There were regular checks of the equipment and environment. This included a health and safety checklist, first aid box, blood pressure machine, fire alarm maintenance and alarm maintenance. The service had an in-date fire risk assessment and evidence of building maintenance and liability insurance.

Patients were happy with the service provided by the nurse consultant but told us there were times they wanted more appointments. The service had addressed this by recruiting a second nurse.

GPHC was led by a nurse consultant who had a history of working in gender affirming care. They had a mental health nurse who worked alongside them and attended the clinic for face-to-face consultations to act as a chaperone and mental health link. They had employed the mental health nurse to work 2 days a week, starting in October 2024, and would increase to 3 days in January 2025. The nurse consultant told us the induction would be comprehensive and include a competency framework and observing consultations. There was an administrator who worked full time for the service. They had fed back that their workload had increased and needed further support; a job advert had gone live for administrative support 3 days a week. The sickness for the service, based on their 2 full time staff members, was 1.8% and they had a turnover of 0%. Managers ensured staff were trained to do their role. Where staff had asked for additional training, this was delivered. All staff attended an annual conference at British Association of Gender Identity Specialists (BAGIS). Additional specialist training sessions were held regularly throughout the year, usually when there was a 5th Wednesday in a month.

We saw there were 2 nurses for each face-to-face appointment which ensured the safety of the staff and the patients.

The managers who led the service were both appropriately qualified and experienced. They were both members of BAGIS and participated in regular education meetings and delivered training on gender affirming care. All staff who prescribed hormones had to be members of BAGIS. Staff underwent an annual appraisal and had 6 weekly 1-2-1 discussions. We looked at 3 of these discussions and found they appeared supportive, discussed training needs, wellbeing and any action items. There was an SOP for the role of the mental health nurse within the clinic.

Patients we spoke with felt the environment was clean and tidy.

The clinic areas were clean, well-organised and had suitable furnishings which were well-maintained. At the time of the assessment, 100% of eligible staff had completed Infection Prevention and Control (IPC) training. The clinic was cleaned weekly by a domestic cleaner. There was a cleaning rota for staff which included a checklist. Staff followed infection control principles. The clinic room had a carpet in it which was against IPC best practice. There was a spill kit available if required. Staff told us they had a contract for waste management, and it was collected on an ad hoc basis.

The clinic was visibly clean and well-organised. There were cleaning records available which showed cleaning was undertaken. We observed the nurse use hand gel before and after taking a patient’s blood pressure and cleaning the couch down in between patients.

Guidance was available for staff in the form of an IPC policy. Audits were completed to assess staffs’ compliance with IPC standards and guidance. We reviewed the IPC audit undertaken in May 2024. It was a detailed self-assessment of IPC within the clinic with an associated action plan. There were policies in place relating to IPC including hand hygiene, bodily fluid spillage policy, needlestick injury policy and disposal of waste.

Patients told us they had been given a lot of information about the medicines both verbally and printed. They had been given a lot of reflection time to make sure they understood the medication and the side effects. The nurse consultant had created a video talking about medication which was sent to all patients prior to their first clinic appointment. Patients told us that was useful and helped them understand the treatment options.

Staff told us they did not keep any medicines on site. They were prescribed by a nurse consultant who was a nurse prescriber via private prescription in line with NHS prescribing guidance. They had recently recruited a second nurse who was also a nurse prescriber. The nurse attempted to reduce costs for patients by entering into a shared care agreement with the GPs where they prescribe and administer the hormone treatment. The clinic had a treatment schedule for medication which had been agreed with an endocrinologist who was available for advice. Patients who were under the age of 18 were started on an adolescent pathway for medication. They were started on a lower dose of hormones and were not allowed to self-administer injectables until they were over the age of 18. All patients who were over the age of 18 were given the option of self-administering medication and were taught how to do this. The nurse had created a video which they sent to patients to assist with administering injections. It was mandatory for the prescriber to see a GP patient summary prior to commencing hormone treatment. This meant they could see the patient’s medical history and summary of medications. The service used medicines in line with national guidance and the Cass Review 2024. If a patient between the age of 16- to 17-years-old were deemed safe and appropriate for feminising treatment, the nurse checked they had reached tanner stage 5 of puberty, including checking bloods and a physical examination including testicular volume prior to using anti-androgens. This was in line with national guidance. They only used anti-androgens as part of the feminising hormone process. Patients received their medication via a private prescription and brought it to their appointments with them for administration when GPs did not administer. The GP received a letter each time a patient received their injection.

We did not observe medicines being given during the assessment. They were given by the nurse where patients were not able to self-administer. We observed the nurse informing the patients of how to take the medications, offering them different routes of medications and making them aware of all of the side effects.

There was a SOP which detailed the clinical pathway and formulary for patients under the age of 18, including patients who may have started treatment prior to being in contact with the service. The service had a pharmacy partner for their private prescriptions; all prescriptions were delivered directly to the patient’s address. All patients had a maximum of 6 months of prescribing before their medication was reviewed by the nurse consultant. There was a detailed prescriber’s policy in place. The service completed a prescribing audit in July 2024 to ensure all prescribing was in line with the clinic’s treatment schedule. The results showed all prescribing as completed in line with the schedule with no concerns raised. There was a medicines management policy. It detailed that some medicines that were used were off-label or unlicensed for gender dysphoria treatment. This meant it was licensed in the UK for a different indication to the one that it was being prescribed for. There were very few medications licensed for gender dysphoria. This meant the nurse prescribed some medications which were unlicensed as no suitable alternatives were available to meet the patient’s needs; this was in line with Nursing and Midwifery Council guidance. They made patients aware of this and the risks that were associated with this when completing the consent form. We observed a conversation with a patient and their parent about this, explaining that it had not been tested at that age group and detailing all the potential side effects. Medicines management was discussed in team meetings and actions created where required. The nurse consultant received Medicines and Healthcare products Regulatory Agency alerts and there was a policy alongside this. The service completed a controlled drugs audit in May 2024 to assess the use of controlled drugs at the clinic. The audit results showed good compliance to the prescribing policy.