Hackenthorpe Lodge SARC

We carried out this announced inspection over two days on 29 and 30 October 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 was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. Two CQC inspectors, supported by a specialist professional advisor, carried out the inspection.

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

Hackenthorpe Lodge SARC 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. Hackenthorpe Lodge is a two-storey building situated on the edge of a housing estate, it has its own carpark. The building, which is police owned, is also used by the police to support vulnerable people to give evidence. The local victim support service has an office on the upper floor but does not see clients at Hackenthorpe Lodge. The SARC was purpose built and has several discreet entrances which staff use to ensure patients do not meet any other visitors to the building.

Hackenthorpe Lodge is designated as the region’s accessible SARC. All patient areas are situated on the ground floor. There is an accessible entrance, which is step free with wide doors. There are two forensic examination rooms, each with their own shower and toilet. One room is designed to better meet the needs of disabled patients, it has additional space and a wet room shower area. The mobility of all patients are fully assessed on first contact with the service, before they enter the building. If the patient’s needs mean they cannot access this SARC the patient can be seen in their place of residence.

The contract for adult SARC provision across Yorkshire and Humberside is jointly commissioned by NHS England and the Police and Crime Commissioners. Services are available for patients 24 hours a day, seven days a week by appointment. The SARC provides services for people of any gender aged 16 and over. Patients can self-refer into the service or be referred by a professional. Most patients access the SARC by a police referral. Children and young people under the age of 16 who require care from a SARC in South Yorkshire are referred to the Child Sexual Assault Assessment Service which is provided by Sheffield Children’s Hospital. Services provided by Sheffield Children’s Hospital were not part of this inspection.

The staff team included a centre manager, Forensic Nurse Examiners (FNEs) and crisis workers who also took on administrative duties. Staff offer referrals to Independent Sexual Violence Advisors (ISVAs) and counsellors, these services are provided by victim support and were therefore not part of this inspection.

The service is provided by a limited company 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 Hackenthorpe Lodge was also the medical director for Mountain healthcare Limited. The registered manager was a member of the Faculty of Forensic and Legal Medicine (FFLM). We have used the terms ‘registered manager’ and ‘centre manager’ to differentiate between the two roles.

During the two-day inspection we spoke with staff members, including the provider’s medical director, the director of nursing, the associate head of healthcare, the centre manager, two forensic nurse examiners and two crisis workers. We reviewed five recruitment files. We looked at the records of 14 patients.

We left comment cards at the location the week before we visited, and we received six responses from people who had used the service. 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 staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• Staff knew how to deal with emergencies. Appropriate medicines and 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 and referral system met clients’ needs.
• 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 service staff had policies to deal with complaints positively and efficiently.
• The staff had suitable information governance arrangements.
• During our inspection we found there were ligature points around the building that staff had not assessed as per the organisation’s policy. Staff rectified this within the week of our inspection.

There were areas where the provider should make improvements. They should:

• Offer, whenever possible, a choice of gender of forensic examiner to all patients.
• Complete the planned programme of level three children’s safeguarding training, including multi agency sessions, for all relevant staff.
• Consider how the communication needs of patients whose first language is not English are met.
• Consider how the communication needs of patients with learning needs are met.
• Complete an accessibility audit for the location.

We identified regulations the provider was not meeting. The provider must:

• Ensure effective systems and processes are in place to assess, monitor and improve the quality and safety of the services provided in the location.
• Ensure decontamination of forensic suites is carried out in accordance with the organisation’s policy.
• Ensure unused equipment is not stored in forensic suites.
• Ensure the examination couch in the forensic suite is fit for purpose.
• Devise and implement a policy covering the safe use and disposal of sharps containers.

Full details of the regulation the provider was not meeting are at the end of this report.

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.