Grange Park SARC

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 5 quality statements under this key question.

Staff identified safeguarding concerns and reported these appropriately. Good links had been established with key partner agencies which helped to improve outcomes for patients.The building was generally clean and well maintained, although building work had not yet started to enable compliance with UKAS forensic standards.

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.

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

Safeguarding policies and procedures were in place which were followed by staff to identify, report and respond to suspected abuse.Staff were clear about their responsibilities and able to give examples of when safeguarding referrals for patients had been made. Information was available about the pathways to follow for each local authority in the geographical area served by the SARC and for adult and child safeguarding pathways.

All staff had completed safeguarding training appropriate to their role. Managers were trained to level 4,sexual offence examiners (SOEs) to level 3, and crisis workers to level 2. Systems were in place to ensure that soon to expire training was refreshed. Staff were provided with appropriately facilitated safeguarding supervision sessions which were documented and provided regularly. Staff told us they felt well supported by managers and able to discuss their safeguarding practice. Additionally,there were daily peer review sessions carried out with other SARCs in the region which gave staff a chance to discuss recent cases and safeguarding referrals they had made.

We reviewed 5 patient records and saw evidence of staff having completed a thorough safeguarding assessment for all patients.This considered the full range of circumstances relating to that patient, including female genital mutilation (FGM) and non-fatal strangulation. When staff made safeguarding referrals,they followed this up with the relevant local authority to ensure that the referral had been received.Staff attended or contributed to strategy meetings as required, although were not always informed of these by the local authority.

The service had Freedom to Speak Up Champions in place, providing staff with support to raise concerns where necessary.

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

The SARC was located on the second floor of a community health centre building and MHL was not responsible for ongoing maintenance and safety checks. The SARC manager sought assurance that relevant safety checks, such as gas safety and servicing, had been carried out. A file was maintained which provided evidence that checks had been completed. Any repair and maintenance work had to be requested through the building’s management team.

One staff member had been trained as a fire marshal, with further training planned for additional staff. Periodic fire drills were carried out and there was training planned for staff to become familiar with using an evacuation chair. There was lift access to the second floor and portable hearing loops were available for patients to use.

CCTV was in operation outside the building and in corridors,in order to enhance the safety of patients and staff. There were panic alarm buttons installed in clinical rooms, enabling staff to call for assistance if required.

The premises had not yet undergone building work to meet ISO and forensic science regulatory standards.There was no confirmed date for building work to start. There were two forensic ‘pods’but we were told that only one patient would be on-site at any one time. Due to the building layout, patient flow couldn’t be managed in a single direction. Therefore, patients exited the building the same way that they entered. Forensic examination rooms were secured when not in use, and a log was maintained of all personnel accessing these areas.

Due to a lack of space, there wasn’t a designated area provided for staff to put on and remove personal protective equipment,and this was carried out in a corridor. A separate storeroom was used exclusively for medical consumables to maintain forensic integrity and reduce the risk of contamination.

The forensic pods contained some ligature risks, such as handrails installed in the bathrooms for mobility purposes.A risk assessment had been carried out and mitigation put in place to lower risk to patients. Staff would stay with patients throughout their time at the SARC. The forensic pod bathroom doors could be opened from the outside in the event of a patient collapse. There was a staff toilet accessed from the main corridor which could not be easily opened from outside, however this was not designated for patient use.

All staff were trained in adult basic life support (BLS) and there was a defibrillator available which was regularly checked.If there was a medical emergency staff would contact 999 to request an ambulance and had done so in a recent case.

At the time of the inspection, the service employed 7 SOEs and 6 crisis workers.One of the SOEs was the SARC manager and 2 were working through their induction period.There had been a small number of gaps in the rota in January and March 2026,but this hadn’t impacted on the service patients received or forensic timescales. The service was now fully staffed and the staff we spoke with told us that staffing levels were good.

Recruitment processes were robust. We reviewed the recruitment files for 2 recently appointed staff members and found that appropriate pre-employment checks and vetting procedures had been completed to ensure their suitability for their roles. Disclosure and Barring Service (DBS) checks were undertaken every 3 years to monitor staff’s suitability.

All new starters completed a structured induction and training programme, which had received formal accreditation from the Faculty of Forensic and Legal Medicine (FFLM).This covered the requirements of the role and included supernumerary time where new starters could shadow more experienced members of the team.There was a robust sign-off process before a new starter could work independently.

Staff received a wide range of training which included information governance,infection prevention and control,medicines management, basic life support and female genital mutilation. Records we reviewed showed that staff had completed all mandatory training relevant to their roles and this was regularly monitored by managers and reported to board level.

All staff received regular supervision and appraisal and the staff we spoke with told us they felt very well supported by managers.Staff received 3t ypes of supervision: safeguarding, clinical, and managerial. There were other routes for staff to raise concerns within the organisation should they not wish to do so during a supervision meeting.

General cleaning was carried out by the community health centre cleaning staff. The SARC staff carried out forensic cleaning after each patient and a monthly deep clean. MHL had policies and procedures in place to guide staff ineffective infection prevention and control (IPC).Staff were up to date with mandatory IPC training.Cleaning checklists were in place and completed for daily cleaning tasks. Regular IPC audits were also undertaken as part of the provider’s schedule of audits which monitored standards and ensured action was taken to remedy any issues. Environmental monitoring was undertaken regularly to check that forensic cleaning had been effective in removing all traces of DNA in forensic areas.

The majority of areas of the SARC were visibly clean and maintained to a standard which enabled effective cleaning. Examination rooms were fitted with sealed flooring however there were some marks where furniture had been moved.There were appropriate hand-washing facilities for staff and shower rooms for patients to use after their examination which were clean. Fixtures and fittings were due to be replaced as part of the overall building works to meet ISO accreditation standards.

Cleaning equipment and materials, such as mop handles,were stored separately from forensic consumables and followed NHS colour-coding guidance.There was only one washing machine available for staff to launder clothing which was located in the staff kitchen due to a lack of space elsewhere. There were plans to appropriately locate the washing machine upon completion of building works.

Only one patient attended the SARC at any one time and, following their examination, staff cleaned the forensic pod to forensic standards. Records were then completed to confirm who had carried out the cleaning and the room sealed.

Clinical and general waste was removed to the building waste storage room prior to being collected by a waste contractor.

The provider had systems and processes in place to support the safe management of medicines. Patient Group Directions (PGDs) were in place and had been read by staff, enabling registered nurses to supply medicines to patients appropriately.

A small range of medicines were held on site and stored in a locked medicine trolley and refrigerator. This included emergency contraception, Hepatitis B vaccines and post-exposure prophylaxis (PEP). Medicines were stored securely, and the temperature of the storage room and refrigerator were monitored daily. Daily stock checks were carried out, and records showed that stock levels were accurate and all items were within their expiry date.

Any medicines issued to patients were recorded within their clinical records, including batch numbers.This was done in each of the patient records we reviewed. The records also demonstrated that each patient was assessed for the need for HIV post-exposure prophylaxis and emergency contraception. These medicines were supplied only when clinically indicated,in line with national guidance.