Solace Centre SARC

We carried out this announced inspection on 30 and 31 March 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.

This service was last inspected on 20 and 21 November 2018, focusing on only services that were provided to anyone who was aged 13 and over. We undertook this visit to inspect a specific part of the service that is offered to patients under 13 years of age, and who had been affected by recent sexual abuse and sexual assault (‘recent’ means less than 72 hours from when the incident took place).

Services provided to patients under 13, and who had been affected by non-recent sexual abuse and sexual assault are undertaken by a different provider and were not inspected as part of this inspection (‘non-recent’ means more than 72 hours since the incident took place).

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

The Solace Centre is based in Cobham and offers a range of support services to anyone across all ages, living within the Surrey area who have experienced sexual abuse or sexual assault, either recently or in the past. The service is accessible 24 hours a day, seven days a week to help people that have been affected by sexual abuse and sexual assault.

For those patients aged 13 and under, forensic medical examiners employed by Mountain Healthcare lead on recent cases. They were supported by pediatricians from a local NHS trust, however, no joint working arrangements for this had been formalised at the time of the visit. This service is available between Monday and Friday (9am-5pm). Referrals are made to an alternative service outside of these hours when needed.

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 service is run. The registered manager was the SARC manager.

The service is located on the first floor of Cobham Community Hospital and has full access for people who use wheelchairs and those with pushchairs. Car parking spaces are available at the hospital including a number of spaces for blue badge holders.

On the days of the inspection, we spoke with the registered manager, the nominated individual who is also the national SARC director for Mountain Healthcare Limited, the medical director of Mountain Healthcare Limited, a forensic medical examiner, a crisis worker, as well as a pediatrician from a local NHS trust.

We looked at policies and procedures and other records about how the service is managed.

Our key findings were:

• The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and patients.
• 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 a culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The service asked staff and patients for feedback about the services they provided.
• The service staff dealt with complaints positively and efficiently.
• The service appeared clean and mostly well maintained.
• The staff had infection control procedures which reflected published guidance.

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

• Have effective governance systems in place to make sure that there was sufficient oversight of key services provided. For example, there were no formal working arrangements, such as service level agreements which clearly outlined the roles and responsibilities of different providers when providing regulated activity.
• Manage the forensic suite in line with its own policies and procedures. For example, leaders had not ensured that the forensic suite had been cleaned after use and some equipment was not suitable for use.
• Manage risk effectively. Formal risk assessments had not always been completed on occasions when risks had been identified.

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

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

• Ensure that the voice of patients, parents and carers are consistently captured within medical records.