The Elms

We carried out this announced inspection on 3 March 2021 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 a second CQC inspector.

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.

Background

Mountain Healthcare Limited (MHL) are commissioned by NHS England (NHSE) and the Cambridgeshire Office of the Police and Crime Commissioner to deliver Sexual Assault Referral Centre (SARC) services to children, young people and adults who have experienced non-recent or recent sexual abuse across the county of Cambridgeshire. The Elms SARC is situated within the grounds of Hinchingbrooke Hospital with discreet access to provide privacy for people entering and leaving. The SARC is accessible 24 hours a day seven days a week, is accessible for patients with limited mobility, and has parking available outside.

The SARC facilities include four forensic examination suites, two adult and two paediatric situated at different ends of the building. Each suite includes a pre-examination room and forensic examination room with accessible bathroom and shower facilities. Two separate aftercare rooms are adjacent to the suites. There is a separate toilet and accessible toilet, storage room, cleaning cupboard, kitchen area and staff office. The SARC is co-located with police colleagues who have an adjoining office, and there is a police live link room as well as three counselling rooms which can be used by external agencies, the police or SARC staff.

The team consists of a SARC manager, a forensic medical examiner, 10 forensic nurse examiners and 11 crisis workers. The SARC manager is in the process of applying to become a member of the Faculty of Forensic and Legal Medicine (FFLM). The forensic medical examiner is a member of the Royal College for Paediatric Child Health (RCPCH).

The service is provided by Mountain Healthcare Limited and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The registered manager at The Elms was the service manager.

During the inspection we spoke with seven members of staff and reviewed eight patient records. We looked at policies and procedures and other records about how the service is managed. 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 provider had robust safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• Care records evidenced a holistic approach to assessing patient needs.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• There were excellent working relationships with co-located police colleagues.
• There was effective leadership and culture of continuous improvement.
• Staff showed care and passion for their work and felt very well supported in their roles.
• Patient feedback was positive about the support they received from the SARC and there had been no complaints.
• Comprehensive information about local services, referral pathways and the operation of the SARC was readily available to staff.
• The provider had good governance arrangements to support the delivery of services from the SARC.
• The environment was clean, welcoming and included age appropriate rooms and equipment with local school artwork and visual distractions for children.
• The provider had infection control procedures which reflected published guidance and had adapted quickly to COVID-19 guidelines to ensure services remained available to patients throughout the pandemic.