Casa Suite 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 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.

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.

There were comprehensive policies and procedures to provide staff with information about identifying, reporting and dealing with suspected abuse, and staff had completed the appropriate level of safeguarding training for their role; all nurse examiners completed level 3 training and senior managers level 4. Staff also attended quarterly safeguarding supervision sessions to discuss complex cases and ensure their knowledge and practice was up to date. We found staff had a good knowledge and understanding of safeguarding procedures and gave us examples of action they had taken to protect vulnerable patients.

Patients were fully assessed for risk factors such as domestic abuse, non-fatal strangulation and substance misuse so that any concerns could be identified, and support offered. Where concerns were identified, they were recorded by staff and nurses were responsible for making any safeguarding referrals. Referrals were automatically made for any 16- or 17-year-old attending the service. Patient records we reviewed showed that appropriate referrals to safeguarding agencies had been made for young people who had attended the SARC.

Safeguarding management was considered as part of each daily case review, and any referrals were actively followed up to ensure they had been received by protection agencies.

Freedom to Speak Up Champions were available if staff wanted to raise any concerns and information about them was on display on the staff office wall.

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 in a secure building, with access that was separate and not open to the public. There was CCTV coverage of the entrance to enhance safety when visiting the premises, although there was no warning signage to inform patients of this.

As the provider did not own the building, it was reliant on other agencies to provide key safety checks and some equipment maintenance. We viewed evidence that gas, fire, and electrical safety checks were completed regularly. Staff told us they undertook evacuations to practice what they would do in the event of a fire,and they regularly flushed through water outlets to reduce the risk of legionella bacteria.

The examination room was only used for forensic medical examinations and was locked when not in use. A numbered seal was attached to the door, and a log was made of all who entered the room for audit trail purposes.

Substances hazardous to health were kept securely in a locked cupboard.

The provider had identified changes to the building that were needed to meet the new standards for UKAS ISO accreditation for forensic services. (The Forensic Science Regulator requires that SARCs are to be accredited to ISO 15189:2022 for the forensic examination process by 2 October 2025). Work for this had been commissioned and was due to start at the time of our inspection.

The premises became very warm at times and staff told us this impacted negatively on their well-being especially when wearing full forensic PPE. Managers were aware of this and had requested air-conditioning be installed as part of the forthcoming refurbishment work.

Patients’ notes were not kept in fireproof filing cabinets but to mitigate this, staff had been uploading notes electronically so the information could not be lost.

Staff undertook training in basic life support, and an automated external defibrillator was available on site. However, some medicines to deal with common medical emergencies such as seizures and asthma attacks were not available for use if needed. The patient bathroom could be opened by staff in case of patient collapse.

The provider had been operating under business continuity planning since July 2023, because of changes to a regional model of provision which had significantly impacted on staffing levels. Figures given to us by the provider showed that there had been 82% staff coverage for the service in August 2025, and 71 % coverage for September 2025. However, managers were able to cover these shortages themselves, and patient care and critical forensic timescales had not been missed.

Although staff told us they enjoyed their work, they stated that the additional travel and overtime necessitated by the regional model sometimes impacted negatively on their morale. The provider was aware of these staff concerns and was working with commissioners to secure funding for additional staffing.

Personnel files we reviewed for 2 recently recruited staff members demonstrated that appropriate pre-employment and vetting checks had been completed to ensure they were suitable for their role, although only one reference had been obtained for a staff member and the provider’s policy was to always obtain 2. Disclosure and Barring Service (DBS) checks were obtained for all staff which were repeated at regular intervals

All staff underwent a comprehensive induction to ensure they had the skills and knowledge for their role, and the provider had recently received formal accreditation from the Faculty of Forensic Legal Medicine (FFLM) for its 5-day staff induction course.

The provider had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Records we viewed showed that staff had completed all essential training for their role including medicines management, female genital mutilation, and infection prevention and control. After a year of employment, nurses were eligible to attend a university accredited course in forensic science. Staff training figures were reported on at board meetings to ensure compliance with training requirements.

Staff told us their competency to do their job was regularly assessed and if they had not undertaken a key skill in the previous 3 months, they were re-assessed by the associate head of healthcare.

All staff received regular supervision and appraisal to identify any training needs and ensure their practice met professional standards, evidence of which we viewed. The provider was updating all their operating procedures to gain ISO accreditation and had arranged a series of learning sessions for staff to engage them with this process and update their practice.

The provider had appropriate policies in place in relation to infection prevention and control, and records showed that all staff were up to date with training. Daily cleaning checks were undertaken, as well as a monthly deep clean of the premises. Quarterly environmental monitoring was in place to evaluate the efficacy of the SARC’s cleaning procedures and DNA management.

There were monthly, quarterly and annual infection prevention and control audits undertaken by the manager to ensure standards were maintained.

We noted that all areas of the SARC were visibly clean and hygienic, including the waiting area, toilet, and corridor. We checked an examination room, and surfaces including walls, floors and cupboard doors were free from dust and visible dirt. The room had sealed coved flooring and modern sealed work surfaces so they could be cleaned easily. A bin was available for the disposal of sharps, although this was not wall mounted to minimise risks to staff and patients. Spill kits were available so that bodily fluids could be cleaned up safely by staff. Cleaning equipment was colour coded to ensure it was used in the correct areas.

Staff scrubs and patient towels were laundered separately to reduce the risk of DNA contamination.

There was controlled access to the forensic examination room to minimise the risk of DNA contamination and a detailed log was kept recording its use. All staff entering the forensic medical examination room wore appropriate protective equipment, including face mask, inner and outer gloves, hair covers and disposable suits. A record of all PPE worn during the examination by the nurse examiner and crisis worker was recorded in each patient’s care record.

After each patient was seen, the crisis worker undertook a full clean of the forensic examination room both to clean it and ensure any residual patient DNA was removed.

The provider had an up-to-date comprehensive medicines management policy for handling and administering medicines within the SARC. Medicines were stored securely in a lockable cupboard in the staff office; however, the temperature of the room regularly exceeded the recommended range, risking the chemical alteration or degradation of the medicines. Although this was in the process of being addressed, we were concerned at the length of time it had taken.

The provider had a limited formulary comprising of emergency contraception and post exposure prophylaxis drugs (PEP) for HIV, but not Hepatitis B. Patient group directions were in place to allow the registered nurses to supply them to patients. Staff maintained a record of all medicines issued to patients in their care record, along with the corresponding batch numbers and expiry dates.

Staff undertook weekly checks of the medicines, and we found stock level records were accurate.

The need for HIV PEP medication was fully assessed before being prescribed to patients to ensure nationally recommended guidance was followed. We found appropriate referrals had been made by staff to local genitourinary medicine services for follow up HIV testing and support.

Relevant patient safety alerts and Medicines and Healthcare products Regulatory Agency notifications were sent directly to the provider’s governance, and health and safety teams who ensured they were disseminated and actioned if needed.