Hackenthorpe Lodge 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. Staff also attended specific safeguarding supervision sessions to ensure their knowledge and practice was up to date.

A full safeguarding assessment was completed for all patients as part of their forensic examination, and covered vulnerabilities including human trafficking and honour-based violence. 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, and for under 18s where female genital mutilation had been identified. Patient records we reviewed showed that appropriate referrals to protection 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. Staff told us of a recent safeguarding case where they had collaborated effectively with partner organisations to ensure the safety and protection of 2women who had been trafficked.

The head of partnership and commissioning for the area told us that the SARC’s staff had recently presented a complex safeguarding case at a performance review meeting attended by NHS leads and police commissioners so that learning from it could be shared across all agencies.

Freedom to Speak Up Champions were available if staff wanted to raise any concerns.

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 and lighting for the car park and entrances to enhance safety when visiting the premises. There was a clear signing in process for visitors to ensure oversight of who entered the building.

As the provider did not own the building, it was reliant on other agencies to provide key safety checks and some equipment maintenance. Fire alarm and portable appliance testing was commissioned by police services. Staff told us they undertook evacuations to practice what they would do in the event of a fire. We viewed a weekly log which showed staff regularly flushed through water outlets to reduce the risk of legionella bacteria. Safety data sheets were available for all hazardous products in use on the premises and spill kits were available to ensure bodily fluids could be cleaned up safely.

There was restricted access to the clinical room where clinical consumables were stored, and plans were in place to introduce swipe card entry to this area for added security.

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).For example, there was no separate donning or doffing area for staff to use before entering one of the examination rooms and patient bathroom fittings were not designed to prevent ligature risk. Patients’ notes were not kept in fireproof filing cabinets but to mitigate this, staff had been uploading notes electronically.

Staff undertook training in basic life support, and equipment and medicines were available to respond to most medical emergencies on site. The bathroom could be opened from the outside by staff in case of patient collapse. However, some medicines to deal with common medical emergencies such as seizures and asthma attacks were not available for use if needed. There was no defibrillator on site and staff had not fully risk assessed or practiced using an off-site one.

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, especially the crisis workers. Staff shortages had resulted in occasional temporary delays to patient care, but this was monitored closely by managers. However new staff had recently been recruited, with an additional nurse and 4 crisis workers being inducted at the time of our inspection.

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.

All staff underwent a comprehensive induction, and the provider had recently received formal accreditation from the Faculty of Forensic Legal Medicine (FFLM) for its 5-day staff induction course. One nurse told us their induction had been ‘brilliant’ giving them confidence in their new role

The provider had arrangements to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. Training records we viewed showed that staff had completed all essential training for their role, and staff told us of forthcoming anti-contamination training that they were looking forward to. After a year of employment, nurses were eligible to attend a university accredited course in forensic science provided by. Staff training figures were reported on at board meetings to ensure compliance with training requirements.

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.

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 complex or distressing cases.

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.

The manager undertook an infection control audit every month to ensure standards were maintained. A regional anti-contamination specialist had recently been employed to provide training and advice for staff.

We noted that all areas of the SARC, were visibly clean and hygienic, including the waiting areas, toilets, and corridors. We checked an examination room and surfaces including walls, floors and cupboard doors were free from dust and visible dirt. The room had sealed 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. Staff disposed of waste in line with clinical standards.

Cleaning equipment was colour coded, and mop heads were single use to minimise the risk of cross contamination. Staff scrubs were laundered on site, with a different washing machine used for patient towels.

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 barrier clothing.

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.

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. Staff also attended specific safeguarding supervision sessions to ensure their knowledge and practice was up to date.

A full safeguarding assessment was completed for all patients as part of their forensic examination, and covered vulnerabilities including human trafficking and honour-based violence. 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, and for under 18s where female genital mutilation had been identified. Patient records we reviewed showed that appropriate referrals to protection 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. Staff told us of a recent safeguarding case where they had collaborated effectively with partner organisations to ensure the safety and protection of 2women who had been trafficked.

The head of partnership and commissioning for the area told us that the SARC’s staff had recently presented a complex safeguarding case at a performance review meeting attended by NHS leads and police commissioners so that learning from it could be shared across all agencies.

Freedom to Speak Up Champions were available if staff wanted to raise any concerns.