• Community
  • Community healthcare service

Willow Tree Children and Young People's SARC

Darlaston Health Centre, Pinfold Street, Wednesbury, WS10 8SY 0808 196 2340

Provided and run by:
Mountain Healthcare Limited

Latest inspection summary

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Background to this inspection

Updated 3 May 2023


Willow Tree Children and Young People’s Sexual Assault Service (CYPSAS) is located within Darlaston Health Centre in Wednesbury, West Midlands. The Sexual Assault Referral Centre (SARC) is situated to the rear of the health centre with discreet access and direct entry to the facilities without the need to enter the main health centre. The service is commissioned by NHS England (NHSE).

Mountain Healthcare Limited (MHL) are commissioned to provide care and support to anyone up to the age of 18 who have been raped or sexually assaulted, as well as those with complex needs up to the age of 25 if they are unable to access the adult service.

The environment for the SARC consists of a patient area with a pre examination room, forensic examination suite with adjoining bathroom and shower facilities, and an open plan aftercare area with kitchen facilities to make drinks and access basic food supplies. There is also an accessible toilet for visitors, a cleaning and storage cupboard, and a temperature controlled store room for medicines and equipment. On the first floor of the health centre is an open plan staff office with kitchen area, a side office, and 2 storage rooms; 1 for laundry, and another for the storage of forensic samples.

The staff team consisted of; 2 SARC managers, 1 safeguarding and strategy manager, 7 forensic medical examiners, 5 forensic nurse examiners and 12 crisis worker/admin. A regional manager had oversight of the service, as well as a national medical director, clinical director and associate medical director.

The service was provided by MHL 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 Willow Tree SARC was the regional manager.

The Clinical Director is a member of the Faculty of Forensic and Legal Medicine (FFLM).

During the inspection we spoke with the regional manager, non-clinical SARC manager, safeguarding and strategy manager, 3 forensic medical examiners (FME), 2 forensic nurse examiners (FNE) and 2 crisis workers. We also looked at policies and procedures, reports and 6 patient records to learn about how the service was managed. We left comment cards at the location the week prior to our visit but did not receive any completed comment cards. We also spoke with commissioners of the service.

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 provider had systems to help them manage risks to children and young people.
  • Staff followed the provider’s safeguarding procedures and understood their responsibilities for safeguarding adults and children.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • Patient care and treatment was delivered in line with current guidelines.
  • Staff treated patients with kindness and compassion and respected their dignity.
  • There was good leadership and a culture of continuous improvement.
  • Staff felt supported and worked well as a team.
  • Complaints were managed and investigated approipriately.
  • The provider had suitable information governance arrangements.
  • The environment appeared clean and well maintained.

There were areas where the provider should make improvements:

  • The provider should improve the support available to the newly created role of safeguarding and strategy manager.

Overall inspection

Updated 3 May 2023

We carried out an announced inspection on 6 February 2023 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.

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.