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Inspection carried out on 17 and 18 September 2019

During a routine inspection

We carried out this announced inspection on 17 and 18 September 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was carried out by two children’s inspectors and a specialist professional advisor.

The inspection was led by two CQC inspectors who were supported by a specialist professional advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

The Casa Suite SARC is a sexual assault referral centre (SARC). The service provides health services and forensic medical examinations to patients aged from 16 years old upwards in the East Riding of Yorkshire who have experienced sexual violence or sexual abuse. The building layout is spread over two floors and there is a large garden in the rear of the premises. There is one examination room in use in the SARC, located on the ground floor, which is used to capacity. The premises are owned and maintained by the police who are based on site.

The service is jointly commissioned by NHS England and the Humberside Police and Crime Commissioner. Services are available 24 hours a day, seven days a week by appointment. The SARC does not offer a walk-in service and is accessible to young people and adults over the age of 16 either by self-referral or by the police.

The staff team consisted of a centre manager, forensic nurse examiners (FNEs), administration staff and crisis workers who also worked as administrators.

The service is provided by a limited company and, as a condition of registration, the company must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The registered manager at The Casa Suite SARC was also the medical director for Mountain Healthcare Limited who is a member of the Faculty of Forensic and Legal Medicine. The registered manager had begun the process of deregistration from the CASA suite SARC and the centre manager had submitted their application to become the new registered manager of this location. We have used the terms ‘registered manager’ and ‘centre manager’ to differentiate between the two roles.

Comment cards were sent to the service prior to our visit and we received three responses from patients who accessed the service. Throughout this report we have used the term ‘patients’ to describe people who use the service to reflect our inspection of the clinical aspects of the SARC.

During our inspection we toured the premises and reviewed the care and health records of 12 patients who had used the service and the records for the management of medicines. We spoke with the centre manager, the registered manager, the director of nursing, the associate head of healthcare, two FNEs and two crisis workers, who also worked as administration workers. We checked six staff recruitment files, minutes of meetings, audits, and information relating to the management of the service.

Our key findings were:

  • The service had systems to help them manage risk.
  • There were suitable safeguarding processes in place and staff knew their responsibilities for safeguarding adults and children.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The appointment/referral system met clients’ needs.
  • The service had effective leadership and a culture of continuous improvement.
  • The staff had suitable information governance arrangements.
  • There were gaps in the staff recruitment procedures.
  • Staff felt involved and supported and worked well as a team.
  • The service asked staff and clients for feedback about the services they provided.
  • The service dealt with complaints positively and efficiently.
  • The service appeared clean and well maintained.
  • The staff followed infection control procedures which reflected published guidance.

There were areas where the provider could make improvements. They should:

  • Consider how the communication needs of people whose first language is not English are met.
  • Offer patients the choice of preferred gender of forensic examiner.
  • Complete the planned programme of level three children’s safeguarding training, including multi agency sessions for all relevant staff.
  • Carry out a lone worker risk assessment specific to the SARC.