Updated 14 February 2020
We carried out this unannounced, focussed inspection on 23 December 2019 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 had met the requirements of a warning notice we issued under Section 29 of the Act following our previous inspection on 29 and 30 October 2019.
The inspection on 23 December was carried out by a CQC inspector and focussed on the question of whether the location was well-led, one of the five key questions in the CQC’s regulatory framework.
Background
Hackenthorpe Lodge is a sexual assault referral centre (SARC). The SARC provides health services and forensic medical examinations to patients aged 16 and over in South Yorkshire who have experienced sexual violence or sexual abuse. Patients under this age receive a similar service elsewhere in Sheffield by a different provider.
The SARC occupies part of a two-storey building owned by South Yorkshire Police, which is used for other purposes as well as the SARC. The centre is purpose-built and occupies the entire ground floor of the building with its own discrete entrances. Further details about the layout of the building are outlined in our report of the previous Inspection.
Hackenthorpe Lodge is jointly commissioned by NHS England and the Police and Crime Commissioners across Yorkshire and Humberside. The centre provides a 24 hours-a-day and seven days-a-week service. Most patients are referred by the police but patients can also self-refer or be referred by another professional.
At the time of this inspection the staff team included a centre manager, Forensic Nurse Examiners (FNE) and crisis workers who also took on administrative duties.
The service is provided by a limited company, Mountain Healthcare Limited. As a condition of their registration the company must have a person registered with the Care Quality Commission as a registered manager. Registered managers have legal responsibility for meeting the requirements on the Health and Social Care Act 2008 and associated regulations about how the service is run. The registered manager at Hackenthorpe Lodge was also the medical director for Mountain Healthcare Limited.
During our previous inspection of 29 and 30 October 2019, we found a number of shortfalls in the governance of the service that amounted to a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014. On 05 November 2019 We issued a warning notice which required the provider to make a number of improvements by 07 December 2019.
The provider subsequently submitted an action plan, which showed the steps they had taken to meet the requirements of the warning notice along with supporting documents and photographs. We reviewed these in advance of our visit on 23 December.
During our visit on 23 December we spoke with both the centre manager and the registered manager. We also reviewed additional documents whilst on site and carried out observations of the physical environment.
We found that the requirements of the warning notice had been met and that the new processes introduced by Mountain Healthcare provided assurances about the ongoing governance of the service.