The Bridgeway 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. Safeguarding was firmly embedded within the SARC and referrals made when required. Care was provided in a way that kept patients safe from avoidable harm. Staff worked collaboratively with the wider healthcare services, support systems and criminal justice agencies to improve outcomes for patients. The environment was well maintained and kept clean. Medicines were safely prescribed and stored.

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.

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 shared with us an example of when they identified that a patient had been trafficked into the country and was a victim of domestic abuse. Staff gained consent from the patient and completed the referrals to the local authority; including MARAC (Multi-Agency Risk Assessment Conference) and the police.

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 prior to patients leaving the SARC, and in addition, a local operating procedure was in place for staff to follow if patients’ mental health remained a concern; this included 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.

The SARC manager had identified the need to improve staff attendance at safeguarding strategy meetings, as there was an absence of invites from the wider safeguarding partnership board. The SARC manager introduced a regular meeting with local partners with the aim of strengthening referral pathways and building awareness of each organisation’s role. Staff recently attended a day session with children’s social care staff to share information and raise the profile of the SARC. Further engagement with paediatricians from a local NHS trust was planned for May 2026 and recent contact had been established with the lead safeguarding nurse in Cumbria.

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

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

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, and 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. The SARC had dedicated fire marshals, they completed weekly fire alarm testing and undertook 6 monthly fire evacuation drills.

At the time of our inspection the SARC was working towards accreditation for UKAS ISO accreditation for forensic services, and plans had been drawn up in collaboration with NHSE and Cumbria Combined Authority to make the necessary changes. All acute forensic and non-acute examinations continued to be completed at the SARC.

The forensic examination room was secured when not in use, with written logs and sealing systems in place to maintain integrity. Staff regularly monitored the room temperature as there was no ventilation system in place and windows within the examination room were not opened to reduce contamination.

Staff had access to the clinical equipment needed for their roles, including a portable colposcope for high quality forensic imaging (a specialized 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 bathroom and toilets that had not been assessed. These included taps, handrails, door handles and door locks. We discussed this with the SARC manager and plans were made to address these concerns. Essential medical equipment for emergency situations in the SARC was limited to a grab bag that included adult and child resuscitation masks and other basic equipment. The SARC did not have an automated electronic defibrillator (AED); however, information was available to staff relating to the nearest community AED. This was a high risk on the service risk register and discussions were ongoing with NHSE. Some emergency medicines were available in the SARC; including adrenaline and emergency contraception, these were stored securely.

All staff had completed all their mandatory training requirements, including life support, health and safety, and fire safety. All children and young people were always supervised during their time at the SARC, this 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; but 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 hard copies of care records were retained.

CCTV was installed at the SARC on the outside of the building only, notices were on display to inform visitors.

The SARC service was staffed by an experienced team, consisting of 2 doctors, 2 nurses and 4 crisis/administrative workers. Between January 2026 and April 2026 rota compliance ranged between 83% and 95%. The service had experienced some long-term absence and staff leaving the service. However, the SARC manager worked proactively to fill gaps in the rota, using regional resources and forecasting in advance potential gaps in staffing. The impact on the service was minimal; 6 patients had been seen out of area and patient care had never been compromised due to shortages. Pathways were in place to support patients out of hours or when the SARC was at capacity to travel to an alternative SARC in Preston. For those under 16 and requiring forensic examination, provision was available at the Royal Victoria Infirmary in Newcastle; however, the SARC manager acknowledged that governance arrangements did require strengthening.

Recruitment was ongoing for a crisis worker, and the service was onboarding an additional crisis worker and a nurse. 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 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. 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 experienced 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 reported to us that they received good support from colleagues and managers, especially after dealing with distressing cases.

Staff had access to MHC employee assistance programme and wellbeing ambassadors were accessible across MHC for additional support. One member of staff we spoke with was a mental health first aider. Staff also had access to TRiM (Trauma Informed management) ambassadors, to support with understanding psychological trauma and its effects.

Staff spoke passionately about their roles and the service they provided to support vulnerable children, young people and adults.

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 clinical room and equipment were cleaned by crisis workers or nurses following examinations. Records were maintained regarding cleaning the clinical room, equipment and children’s toys, and these were audited regularly. The clinical room was cleaned weekly if it had not been used and a deep clean was completed monthly. 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 The Bridgeway was 100%.

We observed that all areas of the SARC were visibly clean and hygienic, including the waiting area, bathroom, and interview room. The clinical 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 no dedicated room for staff to put on or remove personal protective equipment, due to limitations within the premises.

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, Hepatitis B vaccines 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.

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 patient safety alerts from the Medicines and Healthcare products Regulatory Agency.