Acer House SARC

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• 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 the safe key question. Safeguarding was fully integrated into SARC practice, with referrals made appropriately when concerns were identified. Care was delivered in a manner that protected patients from avoidable harm. Staff worked closely with wider health services, support networks, and criminal justice agencies to achieve positive outcomes for patients. The premises were clean and well maintained, and medicines were prescribed, stored, and managed safely.

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.

The provider, Mountain Healthcare (MHC), had safeguarding policies and procedures which provided information to staff about how to identify and report suspected abuse. All staff had completed the appropriate level of training for their role. MHC had a safeguarding lead, and staff were aware of how to make contact if the need arose.

Staff within the national call centre completed an initial safeguarding and risk assessment at the first point of contact for all patients prior to them attending the SARC. Staff completed a mental health safety plan before adult patients left the SARC. In addition, a local operating procedure was in place for staff to follow where there were ongoing mental health concerns, including access to the local crisis team for advice and onward referral. Staff made safeguarding referrals to the local authority, and these were followed up within 72 hours to ensure the referral had been received.

Staff attended strategy meetings to discuss the care of children and young people. The SARC manager and CSAAS lead had worked with multi‑agency partners to highlight the need for strategy meetings. As a result, a pathway was in place with local authorities to ensure SARC or CSAAS staff were invited to these meetings.

MHC had appointed a dedicated strategy coordinator for West and North Yorkshire CSAAS, who, from May 2026, was responsible for managing referrals, coordinating attendance at strategy meetings, and arranging examinations.

Staff received regular safeguarding supervision and all patient cases and contacts with the service were routinely reviewed by staff within 24 hours of each examination.

We found that the service’s website included relevant information and clear signposting for patients and their carers, including specific information for men and children.

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

The SARC operated from police managed premises. Therefore essential premises and safety checks such as fire, portable appliance testing, legionella management, and equipment maintenance were completed regularly by the police estates department to ensure a safe environment. The police shared outcomes of all checks and testing with the SARC manager.

At the time of the inspection, the SARC was awaiting UKAS ISO accreditation for forensic services. SARC managers, the police, and NHS England met every 6 weeks to review progress and ensure continued oversight of the ISO requirements.

Acer House had 2 large forensic examination rooms: a dedicated adult suite and a CSAAS suite. Each suite had its own pre‑assessment room, bathroom, and post‑examination room. The pre-examination room was functional, with appropriate seating and a table to accommodate the initial assessment process. A bathroom, with shower and toilet facilities adjoined the pre-examination room.

At the time of the inspection, the adult suite was not operational due to essential fire door maintenance and was therefore not inspected. During this period, all forensic examinations were carried out in the CSAAS suite.

The SARC premises had been designed to reduce the risk of DNA contamination. There was a clear, one-way flow for patients through pre-examination, forensic examination and post examination areas to minimise the risk of cross contamination. Forensic examination rooms were secured when not in use, with written logs and sealing systems in place to maintain integrity. Room temperatures and air circulation was managed through the high specification ventilation system in place.

Staff had access to the clinical equipment needed for their roles, including a portable colposcope for high quality forensic imaging (a specialised magnifying instrument), allowing staff to support patients who were unable to attend the SARC. Equipment was serviced in line with recommended requirements.

We identified several ligature risks within the pre‑examination bathroom, including grab bars, exposed pipework, and taps. SARC leaders had already recognised these risks, completed a risk assessment, put appropriate mitigation measures in place, and escalated the concerns to police partners. Staff could override bathroom locks in the event of an emergency.

Essential medical equipment for emergency situations in the SARC was a grab bag that included adult and child resuscitation masks and other basic equipment. The SARC had an automated electronic defibrillator (AED); however, this had only been delivered the day before our inspection and was not yet in use. Some emergency medicines were available in the SARC; including emergency contraception and HIV post exposure prophylaxis (PEP) treatment, these were stored securely.

All staff had completed all their mandatory training requirements, including life support, health and safety, and fire safety. Children and young people were always supervised by staff during their time at the SARC, which mitigated the risk regarding potential ligature points. Staff had access to a ligature cutter in the event of an emergency.

Patients’ care records were paper based; although located behind a fire door, they were not stored in fire proof cabinets. However, all care records were scanned into a secure electronic system for each individual patient following each examination. This ensured any fire risk to the integrity of records was mitigated, as electronic copies of care records were retained.

The provider explained that the service had recently experienced some staffing challenges, largely arising from changes to the staffing model. From 1 April 2026, shift patterns at Acer House moved to 12‑hour shifts, covering 09.00 to 21.00. Alongside this, the adult SARC provision was based on a regional model covering Humberside, North, West and South Yorkshire. West and South Yorkshire SARCs provided 24/7 cover for the wider region.

Between January and April 2026, rota compliance improved compared with the previous quarter. The SARC manager took a proactive approach to addressing staffing gaps, drawing on regional resources and forecasting potential shortages in advance. Regular regional SARC manager calls were also held to review staffing compliance. There was no impact on service delivery, and all forensic timeframes were met.

Recruitment was ongoing for a sexual offence examiner, and the service was in the process of onboarding 3 crisis workers for the adult SARC. A crisis worker was in the process of onboarding for the CSAAS. NHS England told us that MHC was committed to recruiting staff with the right skills and experience and had held an open day at Acer House to promote the service. NHS England also considered the move from recruiting forensic nurse examiners to sexual offence examiners to be positive, as it widened the potential applicant pool to include other professionals, such as midwives.

Information we reviewed for the most recently recruited staff members demonstrated that appropriate pre-employment and vetting checks had been completed to ensure they were suitable for their role.

All new staff underwent the MHC national induction programme, which covered essential training in infection control, safeguarding, and information governance. Staff shadowed colleagues as part of the SARC induction until assessed as competent to undertake their role. One staff member told us they had completed additional shadow shifts because they wanted to provide the best possible care for patients. Crisis workers completed a competency training portfolio booklet to record their activities during and following their induction. Clinicians completed an end-to-end assessment before they worked independently, this comprehensive assessment was also repeated annually for all clinicians. Staff also had access to additional training to maintain competence in areas of practice that they might not routinely experience over any 3-month period. For example, simulations were used for taking blood and assessing men’s needs.

All staff received regular supervision and appraisal to identify any training needs and ensure their practice met professional standards. Staff told us they received support from colleagues and managers.

Staff had access to MHC’s employee assistance programme and wellbeing ambassadors were accessible across MHC for additional support. Staff also had access to TRiM (Trauma Informed management) ambassadors, to support with understanding psychological trauma and its effects.

Staff spoke with clear enthusiasm and commitment about their roles and the service they provided to support vulnerable children, young people and adults.

Freedom to Speak Up Champions were available if staff wanted to raise any concerns and staff were aware of this.

There were appropriate policies in place in relation to infection prevention and control, and staff received training in this area. A cleaning contractor provided a daily cleaning service of non-forensic areas, and the examination rooms and equipment were cleaned by crisis workers or nurses following examinations. Records were maintained regarding cleaning of forensic examination rooms, equipment and children’s toys, and these were audited regularly. The forensic examination rooms were cleaned weekly if they had not been used and a deep clean was completed monthly. The SARC had dedicated rooms for cleaning equipment. All staff were up to date with infection prevention and control training.

Additional quarterly environmental testing for DNA contamination was completed by anticontamination champions, compliance at Acer House was 100%.

We observed that all areas of the SARC were visibly clean and hygienic, including the waiting area, bathroom, and interview room. The forensic examination room surfaces including walls, floors and cupboard doors were free from dust and visible dirt. The room had sealed flooring so it could be cleaned easily.

Scrubs were available for staff to use, and staff had access to separate onsite laundry facilities. Patient and staff laundry was managed separately to reduce the risk of cross contamination and records were maintained. A bin was available for the disposal of sharps, which was dated when opened and not overfull. There was a dedicated room for staff to put on or remove personal protective equipment, and staff had access to a shower room for use whilst on duty.

Staff wore appropriate PPE, including face mask, gloves, and disposable aprons.

The provider had medicines management procedures for the safe handling and administration of medicines and patient group directions were in place to allow the registered nurses to supply medicines to patients.

Doctors prescribed medicines individually to patients which included emergency contraception, and HIV post exposure prophylaxis (PEP) treatment. A small stock of medicines such as pain relief for adults and children was also available to give to patients if needed. Records showed that the need for PEP and emergency contraception was fully assessed and dispensed according to nationally recommended guidance. The service did not prescribe or hold stock of hepatitis B vaccines or adrenaline, as these were not a requirement of the MHC contract.

Medicines were stored securely and staff routinely monitored the fridge temperature to ensure medicines were stored safely. Staff completed regular audits of medicines; including weekly and monthly checks; and quarterly audits. Outcomes were shared with staff during team meetings and during 1:1 supervision.

Systems were in place to ensure staff were notified of any national safety alerts.