Updated 15 September 2022
Summary findings
We carried out this announced inspection on 26 and 27 July 2022 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by two CQC inspectors as well as a specialist professional advisor.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?
These questions form the framework for the areas we look at during the inspection
Are services safe?
We found that this service was providing safe care in accordance with the relevant regulations.
Are services effective?
We found that this service was providing effective care in accordance with the relevant regulations
Are services caring?
We found that this service was providing caring services in accordance with the relevant regulations.
Are services responsive to people’s needs?
We found that this service was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found that this service was providing well-led care in accordance with the relevant regulations.
Background
Teesside Sexual Assault Referral Centre (SARC) and The Meadows SARC are commissioned by NHS England and the Police and Crime Commissioner and cover the population of Teesside, Durham and County Durham. The two SARCs operate as a hub and spoke model, with Teeside SARC being the main site. Forensic Nurse Examiners (FNEs) and Crisis Workers based at Teesside also provide forensic examination and support to patients at the satellite site, the Meadows SARC. The SARC service is available 24 hours a day, seven days a week including public holidays to people over the age of 18. The service provides advice to police and patients, support following recent and non-recent sexual assault, and also provides acute forensic examination. The service offers onward referrals to a number of services, including counselling services and Independent Sexual Violence Advisors. Both SARCs will see young people aged between 16-18 by exception if they do not wish to be seen at the paediatric SARC in Newcastle.
Teesside SARC is situated in an accessible building for wheelchair and pushchair users in a ground floor building which is part of a health village comprising of GP practices, dental practices and speech and language therapy services. There is immediate parking outside the SARC as well as additional parking nearby. There is one forensic examination room which includes a changing area, forensic toilet and shower facility. There is a waiting area and separate room for patients, storage facilities and changing facilities for staff as well as office and kitchen space for staff.
The Meadows SARC is next to a public park and is also accessible to wheelchair and pushchair users with ramps and lift access. There is one forensic medical examination room and one forensic toilet and shower. There is a small kitchenette, waiting area and toilet facilities for relatives or friends. There is a meeting/interview room.
Both Teeside SARC and the Meadows SARC provide a pleasant environment for patients accessing services there.
We left comment cards at Teesside SARC the week before our visit, we received five feedback cards. We also spoke with commissioners of the service. For the purpose of the report, when we refer to ‘the service we are referring to services provided at both tTeeside SARC and the Meadows.
We examined policies and procedures and records about how the service is managed. We looked at 20 sets of clinical records across both sites.
The service is provided by Mountain Healthcare Limited and as a condition of registration they must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibilities for meeting the requirements of the health and social care act 2008 and associated regulations about how the services run. The registered manager is the associate head of healthcare and Forensic Nurse Examiner (FNE) for the provider.
Throughout this report we have used the term ‘patients’to describe people who use the service to reflect our inspection of the clinical aspects of the SARC.
Our key findings were:
- The service had systems to help them manage risk.
- The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The service had thorough staff recruitment procedures.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- The appointment/referral system met clients’ needs.
- The service had effective leadership and culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The service asked staff and clients for feedback about the services they provided.
- The staff had suitable information governance arrangements.
- The service appeared clean and well maintained.
- The staff had infection control procedures and COVID-19 protocols which reflected published guidance.
There were areas where the provider could make improvements. They should:
- Ensure a validated medical grade cool box is used to transport Hepatitis B vaccines between SARCs so the temperature of vaccines are controlled safely and the cold chain is maintained.
- Ensure all staff have an understanding of storage and transportation of medicines in hot temperature
- Ensure the voice of patients are consistently captured within medical records
- Introduce procedures so that practitioners make a full written record clearly documenting full details around assessments or interventions
- Provide leaflets in other languages and in an accessible format