Grange Park SARC

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 1 quality statement under the well-led key question. Governance systems were robust and ensured patients received a safe and effective service. There was a focus on continuous improvement and staff were supported in their work by managers.

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

There were clear lines of responsibility and accountability within the service. The SARC manager had overall responsibility for the day-to-day running of Grange Park SARC and for ensuring compliance with operational protocols. They were supported by an associate head of healthcare and a regional contracts director, both of whom provided oversight and visited the service regularly.

The provider had policies and procedures in place to support the operation of the SARC and these were reviewed and updated as required. All organisational policies were accessible to staff via the provider’s intranet system.

Systems were in place to ensure staff remained up to date with current evidence-based practice. Faculty of Forensic and Legal Medicine (FFLM) guidance was reviewed every 6 months by senior clinical managers to ensure ongoing compliance. Updates were communicated through staff bulletins, the provider’s intranet, and revised standard operating procedures.

There was a comprehensive governance framework which supported learning and good practice well as identifying areas for improvement.A new annual audit plan had been developed to assess key areas of performance such as infection control and record keeping standards. We saw that daily, weekly and monthly check lists were in use to ensure essential tasks were completed. A service level risk register was maintained which identified key risks to service delivery and steps taken to mitigate these.

Staff received regular supervision and could raise any concerns and suggestions here and at local team meetings. There were daily case review meetings which included colleagues from other SARCs which offered assurance about patient care. There were additional structured forums to review performance and manage risk. These included quarterly Clinical Governance Board meetings, regional quarterly meetings, local partnership meetings and weekly regional managers’ meetings.

We received positive feedback about the service from police colleagues who regularly work with SARC staff in supporting survivors of sexual assault. A visit by the NHS England commissioning and quality team was positive and the provider had acted on any points for improvement. Feedback received from patients and other professionals was mostly positive and the provider acted on any feedback to make further improvements.

Any incidents or adverse events were reported through the‘non-conformance’ system and investigated appropriately. There had been recent improvements in how investigation outcomes and learning was shared,with staff now being routinely updated regarding any changes to working practice. Staff told us they felt the culture of the service was open and transparent and they felt able to report incidents confidently.

The provider demonstrated a strong commitment to staff well-being. Regular well-being surveys were undertaken, and well-being ambassadors were appointed across each region. Staff also had access to trained mental health first aiders, trauma risk management practitioners, and counselling services.

Staff told us the service was well-led and felt there was excellent teamwork with staff pulling together to help one another. There was visible leadership with the SARC manager being on site during the week.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The judgement for Governance, management and sustainability is based on the latest evidence we assessed for the Well-led key question.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.