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Inspection carried out on 11 & 12 June 2019

During a routine inspection

We carried out this announced inspection on 11 & 12 June 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. The inspection was led by a CQC inspector who was supported by a second CQC inspector and a specialist professional advisor.

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.


The Horizon SARC Castle Vale is located in the Castle Vale area of Birmingham and provides services to adults aged 18 and over. Children aged 16 or 17 may be seen at the centre upon request.

The service is accessible 24 hours a day, 7 days a week but only opens on request. Staff are based at another Sexual Assault Referral Centre (SARC) and attend this location should a patient request to be seen here. The location is secure and only SARC staff can access it.

The service is delivered from within a primary care centre and the provider leases a part of the building. The building is accessible for patients with disabilities. The accommodation includes one forensic suite with an adjoining shower room and a separate waiting room.

The team includes a service manager, two full time forensic nurse examiners (FNEs) and four FNEs who have flexible contracts. There are 14 crisis workers, two of whom cover administrative duties in the office. The service manager is also a FNE and trained as a crisis worker and can provide cover if required. There are four Forensic Medical Examiners (FMEs) who provide cover should an FNE not be available or if particular skills and expertise are required.

The service is provided by G4S Health Services (UK) 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 responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations regarding how the service is run. The service is commissioned by NHS England in the West Midlands.

During the inspection we spoke with five staff members, and looked at policies, procedures and other records about how the service was managed. We reviewed care records for 26 patients who had accessed the SARC within the last 12 months. During the period between April 2018 – March 2019, 179 patients had accessed services at Horizon SARC Castle Vale. We were unable to speak with any patients during this inspection. 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:

  • There were suitable safeguarding processes and staff understood their responsibilities for safeguarding their patients.
  • The service had appropriate systems to help them manage risk.
  • The service had thorough staff recruitment procedures.
  • Systems were in place to support staff to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • Care and treatment was provided in line with current guidelines and staff asked for patients’ consent.
  • The service appeared visually clean and well maintained.
  • Staff had access to a wide range of training and felt supported.
  • Patients were treated with dignity and respect and their privacy and personal information were protected.
  • Patients were seen quickly following their referral or an appointment was made for an appropriate time.
  • There was a process in place for patients to complain about the service.
  • The service had effective leadership and there was a positive culture which encouraged continuous improvement.
  • There was a strong ethic of teamwork and openness.
  • Patients and staff were asked for their feedback about the service.
  • There were good clinical governance arrangements in place which supported staff to provide patients with a high quality service.

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

  • Review all policies and procedures to ensure they are up to date.
  • Implement an effective system for monitoring staff training.
  • Ensure that the complaints process is accessible to all patients and contains relevant details about escalation of complaints.