The Angel Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 6 quality statements under this key question. We found that the provider had systems in place to ensure patient safety, including safeguarding vulnerable people from abuse and maintaining the required standards of infection prevention and control. Emergency equipment was available however there was no defibrillator on site.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Learning culture is based on the latest evidence we assessed for the Safe key question.

Staff had good knowledge of local agencies and services and made appropriate and timely referrals to promote continuity of care for patients.

The SARC had clear and effective referral pathways. The SARC’s website provided referral criteria, information and advice. The provider actively promoted their service in the local area and had made links with a range of community services including GPs, sexual health clinics, hospitals, universities, police, and charitable organisations. The provider worked closely with other services, in particular, the police and safeguarding team to ensure that care and treatment was coordinated for the benefit of patients. The service had pathways into other services, including GPs, sexual health and counselling, and made referrals or shared information with the patient’s consent.

The provider had a positive culture of safety, based on openness and honesty. Staff knew how and when to report safety concerns and incidents using the providers electronic system. They completed online forms that created an incident management record that managers and clinical leads used to investigate and identify learning. We reviewed the incidents reported in the 12 months prior to our inspection and found that staff reported a wide range of incidents. Learning was shared with the wider staff team during supervision, peer review and team meetings.

The provider had an up-to-date comprehensive safeguarding policy that clearly set out local procedures and protocols. The service had good working relationships with local agencies such as the police, social services and local hospitals.

Staff understood their safeguarding responsibilities and had received appropriate training. Assessments had questions that helped staff identify patient’s vulnerability, risks and needs. Records showed that staff identified safeguarding concerns, made timely safeguarding referrals and followed them up.

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

The SARC was in new purpose-built premises with excellent facilities for patients and staff. The premises were designed to meet the new standards for UKAS ISO accreditation for forensic services. (The Forensic Science Regulator requires that SARCs are to be accredited to ISO 15189:2022 for the forensic examination process by 2 October 2025). Patient areas had safety features to prevent ligature risk and locked bathroom doors could be opened from the outside. The police were responsible for the maintenance and general cleanliness of the SARC building. SARC staff reported any faults to the police and said that they received timely responses. A maintenance team completed weekly checks on the building that included testing the alarm systems.

Staff had access to the clinical equipment and medicines needed to perform their roles effectively. Equipment was safe and serviced in line with the provider’s policy. Staff knew how to use a colposcope (specialist equipment used for making records of intimate images during examinations, including high-quality photographs and videos). Forensic samples were managed in line with guidance from the Faculty for Forensic and Legal Medicine (FFLM). Control of Substances Hazardous to Health (COSHH) safety data sheets were available for all cleaning products in use at the SARC.

Staff knew how to respond to a medical emergency and were up to date with their basic and immediate life support training. Emergency equipment was available however there was no defibrillator on site. Managers had identified the need for an on-site defibrillator and had requested funding for this. Until this was available, staff had the option to utilise a public defibrillator situated a short distance from the SARC building.

The provider had robust processes for recruiting staff underpinned by a comprehensive recruitment policy. Only suitably qualified, skilled and experienced people were employed. All staff had to complete Disclosure and Barring Service (DBS) checks, which were repeated at regular intervals. The provider had an electronic HR system which alerted managers to any upcoming expiry dates for staff DBS checks and professional registrations.

Staffing levels were good and there were sufficient staff with additional resilience to meet patient needs. Staff were appropriately qualified and skilled and offered a comprehensive induction and training package to support their employment.

Staff were up to date with their mandatory training that included life support, infection prevention and control, information governance, and safeguarding. The provider offered a wide range of additional training opportunities to staff such as sexual health awareness; courses were delivered through e-learning with some face-to-face courses available. Staff received specific training on how to use a colposcope. The staff we spoke with felt they had good training opportunities with the provider.

The provider had a supervision policy that set out minimum supervision requirements for staff. All staff were offered supervision monthly whether that be managerial, safeguarding or clinical supervision. Regular peer review sessions were also held and staff we spoke with felt well supported by their managers and colleagues.

All staff received an annual appraisal. The provider used an intranet called ‘The Peak’ to share information and resources with staff including a training calendar, policies and procedures, health and safety notices, and organisational bulletins.

The provider carried out an annual infection prevention and control audit which identified appropriate actions. We saw that these were addressed promptly, and the facilities viewed during the inspection complied with infection prevention standards.

Staff carried out forensic decontamination cleaning after each case and ensured that clinical areas met the appropriate infection control standards. Staff maintained routine weekly and monthly deep cleaning logs; quarterly environmental monitoring was in place to test the efficacy of the SARC’s cleaning procedures and DNA management. Staff disposed of waste in line with clinical standards.

Personal protective equipment (PPE) was readily available and there were good stock levels of consumables that were stored tidily in separate boxes, labelled, and arranged according to their level of risk.

The provider had an up-to-date comprehensive medicines management policy for handling and administering medicines within the SARC. Medicines were stored in locked cabinets or a fridge in a designated room. Staff checked the stock levels and expiry dates regularly and recorded room and fridge temperatures daily. An escalation policy was in place to address any temperatures recorded out of range; however, this had not been an issue in the premises to date.

The provider had Patient Group Directions (PGDs) for medicines such as hepatitis B vaccinations, emergency contraception and HIV post exposure prophylaxis after sexual exposure (PEPSE). Records we reviewed during the inspection showed that staff assessed patients’ injuries using an algorithm to determine whether it was appropriate to offer any medicines. Detailed information was documented on the patient assessment of any medicines administered including paracetamol for pain relief. Staff gave patients appropriate information about any medicines they were offered.