Updated 12 July 2023
Summary findings
We carried out this targeted announced inspection on 26th April 2023 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions to follow up on concerns that had been identified in a previous inspection which was undertaken on 2nd and 3rd August 2022. 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 and an additional CQC inspector.
We focused on specific parts of the service’s governance. These are:
- To ensure an effective mechanism to identify and remove out of date consumables, for example swabs and bandages
- To ensure all clinical records are legible and that corrections meet record keeping standards
- To ensure effective mechanisms are in place to monitor and mitigate risk
- To ensure staff receive outcomes and learning from incidents they have reported
This targeted inspection only looked at this key question;
• Is it well-led?
We found that the provider was compliant with Regulation 17 (1), 17 (2) (b) and 17 (2) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We do not currently rate the services provided in sexual assault referral centres.
Background
Beech House SARC (Sexual Assault Referral Centre) is situated in Maidstone and provides services to adults and children who have experienced sexual abuse or sexual violence either recently, or in the past. The service is provided by Mountain Healthcare Limited (MHL) and delivered from secure rented premises in a quiet commercial estate. There is parking to the front of the building. The service is on the ground floor.
The SARC includes two forensic suites, (one for adults and one for children) each contains an adjoining forensic waiting area, medical examination room, shower room and a non-forensic aftercare room.
For the purpose of this targeted inspection we focused on provision for 0-18- year olds. The adult service was inspected by the CQC in 2018. The service is provided by MHL and is commissioned by NHSE (National Health Service England) and the Kent Police and Crime Commissioner.
The service offer is 9am - 5pm Monday to Friday excluding Bank Holidays. If children need be seen outside of this time frame to meet the forensic window alternative arrangements are made.
On the day of the inspection, we spoke with regional managers for Mountain Healthcare Limited and a crisis worker.
We looked at policies and procedures and other records about how the service is managed.
Our key findings were:
- Improvements had been made since our last inspection of 2nd and 3rd August 2022.
- All consumables seen in the storage area were in date. Leaders had created a Standard Operating Procedure (SOP) regarding the management of equipment and consumable items. We did see a discrepancy for the number of items currently held in the storage area. This was addressed immediately by correcting the issue and a reminder to sent to all staff to follow the SOP.
- Clinical records reviewed were legible and adhered to record keeping standards
- Clear mechanisms were in place to manage and mitigate risk. We saw a number of examples of how risk is identified, managed, logged and then reviewed by leaders and staff. Leaders have also increased the frequency of meetings with the SARC manager to review identified risks and mitigations.
- We saw how staff receive learning and outcomes from incidents reported in a number of ways. Through individual meetings, within team meetings and by information made available on the service intranet.