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We are carrying out a review of quality at The Horizon SARC. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Updated 15 March 2021


Mountain Healthcare Limited (MHL) provides sexual assault referral centre (SARC) services in different parts of the country. NHS England has commissioned MHL to provide the ‘West Midlands Children and Young Person Sexual Assault Service’ for children who live in the West Midlands geographical area covering 14 local authorities and four police forces. This SARC provides forensic medical examinations and some related health services for children aged under 18 who have experienced sexual assault or abuse. This service is registered with CQC as The Horizon SARC. We have referred to children who use the service as ‘patients’ predominantly in this report.

The service is provided from five sites based on a ‘hub and spoke’ model. The principal, or ‘hub’ site is The Horizon SARC in Walsall where the provider retains patients’ records; the hub site is the location registered with CQC. There are four ‘spoke’ sites; Grange Park SARC in Stoke-on-Trent, The Glade SARC at Bransford in Worcester, the Blue Sky Centre in Nuneaton and a facility at the Birmingham Children's Hospital. The latter site had been closed since the beginning of restrictions arising from the COVID 19 pandemic and so was not included in our inspection. Each of these sites is controlled by the provider of the adult SARC service for the areas in which they are situated; G4S Health Services (UK) Limited (G4S). We have separately inspected and reported on the services provided by G4S from those locations

The Horizon SARC is available for patients who report sexual abuse or assault that occurred on a ‘recent’ basis (within the previous 21 days) or on a ‘non-recent’ basis (outside that timeframe). All patients who report a recent assault or abuse visit the Walsall site for their examination and this is accessible 24 hours each day. Patients who report a ‘non-recent’ assault or abuse can visit a daily clinic at whichever of the Walsall, Stoke, Bransford or Nuneaton sites is most convenient for them. The non-recent service rotates from site-to-site each day and is accessible between 9am and 5pm Monday to Friday by prior appointment.

All patients may be referred through safeguarding procedures or may be brought by the local police. Patients aged 13 and over may also choose to refer themselves subject to certain safeguards as set out later in this report. Patients aged 16 and 17 can also choose to use the adult SARC service for the area they live in.

The service is also available for young adults with complex needs up to the age of 25 although none of the patients who had used the service since May 2020 were over the age of 17.

The service is accessible for both patients and professionals through the provider’s 24-hour single point of access known as the ‘Pathway and support service’.

All patients see a crisis worker and a sexual offence examiner when they attend the service. G4S are sub-contracted to MHL to provide crisis workers for the children and young person’s service and to work alongside MHL sexual offence examiners using MHL procedures.

Patients under 13 years of age who have experienced either recent or non-recent abuse are seen by doctors known as forensic medical examiners (FME). FMEs also carry out all examinations of patients aged 13 and over who have reported non-recent sexual assault.

All FMEs are part of a rota that covers The Horizon SARC as well as the rotas that cover other SARC locations run by MHL. Six of the 11 FMEs who are on the Horizon SARC rota are members of the Faculty of Forensic and Legal Medicine of the Royal College of Physicians (the FFLM).

Patients aged 13 and over who have experienced recent sexual assault are seen by forensic nurse examiners (FNE). There are five members of the FNE team that work solely at this SARC.

The SARC refers all patients to children’s independent sexual violence adviser (ChISVA) services provided by a local advocacy and advice organisation following their initial examination. Patients are also referred to therapeutic and counselling services where this is required.

The service is also commissioned to provide sexually transmitted infection (STI) screening for all patients who use the SARC aged under 13 in the West Midlands area. The service refers all other patients aged 13 and over to local genitourinary medicine (GUM) and sexual health services in the area where they live.

As MHL are a limited company, they must have a manager registered with the Care Quality Commission as part of the conditions of their registration. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the provider runs the service. The registered manager for this service is the organisation’s medical director who is also part of the MHL senior leadership team. However, a centre manager, who is part of the FNE team, conducts the day-to-day management of the SARC.

During the inspection we spoke with the provider’s senior leadership team that have overall responsibility for the service, including the registered manager. We also spoke with two of the FMEs, three of the FNEs (including the centre manager) and one of the crisis workers.

We carried out visits to the Walsall hub site and each of the spoke sites at Bransford, Stoke and Nuneaton to review the environment and facilities for patients. We also looked at the policies and procedures that staff use at the SARC.

We reviewed the records of eight of the patients who had used the service since May 2020, and we left comment cards at all four sites in the two weeks prior to our visit.

Our key findings were

  • Staff knew how to deal with emergencies and appropriate medicines and life-saving equipment were available.
  • The physical environment was clean, well maintained, and staff used infection control procedures which reflected published guidance.
  • The provider operated safe staff recruitment procedures.
  • The clinical staff provided patients’ care and treatment in line with current guidelines except where we have set out below.
  • Staff treated patients with dignity, respect and compassion and took care to protect their privacy and personal information.
  • The single point of access referral system met patients’ needs.
  • Staff received a range of specialist training for their role, felt well-supported and worked together as a team.
  • The provider learned lessons from positive, adverse and irregular events.
  • The service asked staff and patients for feedback about the services they provided.
  • The staff complied with appropriate information governance arrangements.

We identified regulations the provider was not meeting and have issued warning notices under section 29 Health and Social Care Act 2008. The provider must:

  • Carry out, and document, comprehensive assessments of patients to enable staff to provide safe care and treatment to meet their needs.
  • Improve the way staff are enabled to identify and respond to potential safeguarding risks.
  • Improve the arrangements for assessing and monitoring the quality and safety of services for patients.

Full details of the regulation/s the provider was not meeting are at the end of this report.

We identified areas where the provider should make improvements. The provider should:

  • Demonstrate the involvement of patients in their assessments by ensuring that children’s voices are better represented in documentation.
  • Take steps to develop the website for the service so that it presents consistent information about how to access the service.
Inspection areas


Enforcement action

Updated 15 March 2021

Safety systems and processes

Mountain Healthcare Limited (MHL) had implemented policies relating to safety and communicated these to all staff working in the children and young persons’ service. All policies we reviewed were up to date with scheduled review dates. These were supported by regular, mandatory training in key safety topics such as immediate life support, health and safety, and infection control.

Staff had received safeguarding training that met national, intercollegiate guidance on safeguarding roles and competencies that applied to their role. Staff also received monthly operational supervision and quarterly safeguarding supervision that involved case discussion. Staff kept a personalised safeguarding passport; this was a log that showed the dates they had achieved their mandatory training, including safeguarding training, and the dates they had engaged in other activity and supervision sessions to maintain their safeguarding competence.

The SARC followed safeguarding procedures for each of the local areas in the West Midlands within their coverage. Patients under 13 were only seen at the SARC following a referral to the service through those processes. The provider’s policy was to make referrals through local safeguarding procedures for all patients aged 13 and over who self-referred subject to them being assessed as to whether they were able to consent to this. The occasions when a referral was not made were rare, however, and a referral would still be made without a child’s agreement if there were continuing risks of sexual assault or abuse to the child or other children. As part of this process all patients aged 13 and over were also assessed for the risks of child sexual exploitation using an established risk assessment tool.

The manager used a safeguarding tracker tool to ensure that action to address risks for each child was taken as appropriate. There was also a safeguarding audit tool completed for each of the children’s case records designed to help examiners ensure that safeguarding considerations had been properly addressed for each child. However, we found some shortfalls in safeguarding practice that these systems had not identified.

The provider used a template known as a ‘safeguarding alert form’ to communicate information to local authorities in relation to children who were already known to children's social care. This form had been used in seven of the eight children’s records we looked at but these, too, were variable in quality. For four of the eight children, there was limited information and analysis in the form, which was insufficient to support multi-agency partners to make effective safeguarding decisions.

In the eight records we reviewed, the level of professional curiosity or analysis of risks to children arising from the circumstances of their attendance at the SARC was variable. For four of the children it was superficial and for one child professional curiosity was not evident at all. Professional curiosity means being alert to safeguarding risks posed to children from potential abusers or from the child’s situation and the capacity and communication skill of staff to explore and understand those risks.

Due to these shortfalls we have used our enforcement powers and issued MHL with a warning notice requiring them to become compliant with Regulation 13(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 05 March 2021.

Risks to patients

There was a clear infection control policy and the centre manager was identified as the lead staff member for ensuring staff were aware of it and complied with it. The manager had also carried out a baseline infection control audit of The Horizon SARC in October 2020. We were assured that all infection control risks were identified and addressed through an action plan derived from this audit.

Risks to patients from the environment were accurately assessed and actions taken to reduce or minimise the risks. For example, the centre manager conducted a comprehensive ligature and suicide risk assessment for the Walsall site in March 2020.

G4S were responsible for the cleanliness and safety of the environment. This included the disposal of waste and clinical waste, as well as the stringent cleaning of the forensic examination and waiting rooms to prevent the cross-contamination of contact evidence. The managers of both the MHL and the G4S services liaised regularly about identifying and mitigating potential risks arising from the environment and this arrangement was effective.

There were regular contract meetings between MHL and G4S leadership teams and both centre managers, informed by a G4S performance report. This process ensured that any risks arising from each of the four premises, as well as in relation to the use of G4S crisis workers, were properly identified and discussed and action taken to address these.

There were sufficient staff to meet patients’ needs either by appointment at the non-recent clinics or on an on-call basis within one hour for children reporting recent abuse. The rotas for FMEs and FNEs for the months before and after the inspection showed that there was enough staff to cover the planned hours of operation. The manager checked staff numbers and response times as part of their quarterly monitoring and reporting process and through the contract meetings with G4S in respect of the crisis workers.

Staff were employed in line with the provider’s safer recruitment policy. Pre-employment safety checks included enhanced Disclosure and Barring Service (DBS) checks and an extensive interview process. The provider’s central HR team validated references, qualifications and professional registration. Staff were subject of additional vetting through the local police before being employed. The manager had oversight of this through the provider’s HR database.

Staff assured the safety of patients that were identified as being at risk of harm or with urgent health concerns. For example, the examination included a full assessment for the need for post-exposure prophylaxis after sexual exposure (PEPSE), Hepatitis B and emergency contraception as detailed in ‘effective’ below.

NHS England commissioned MHL to undertake screening for sexually transmitted infections (STI) for all patients under 13. The service referred all patients aged 13 and over to the (GUM) or sexual health services and their attendance was tracked as part of the provider’s follow-up processes.

Staff at the SARC made a follow-up call to all patients or their parents or carers at three weeks after their visit to check on their wellbeing and ensure they fully understood and were engaged with any onward referrals that had been made. The service offered all patients under 13 a follow-up appointment with the SARC at two weeks for STI screening and at three months for blood borne virus testing to ensure they were protected from ongoing risks.

Information to deliver safe care and treatment

The service used a range of other templates and forms for recording information about the examination, including notes made by crisis workers, information about aftercare and templates for sharing information with other organisations. These templates were part of the patients’ records.

Staff used an electronic system to record information about patients following the initial referral to the service. The FMEs, FNEs and crisis workers made their records in hard-copy format (see below under ‘effective’). The provider securely transported paper records for children seen at either the Bransford, Stoke or Nuneaton sites to the Walsall site where they were held prior to undergoing a case review and then stored. Records were stored in locked facilities in the Walsall office with controlled access ensuring that patients’ personal information was secure.

Staff used specialist equipment, known as a colposcope, in each site for making records of intimate images during examinations, including high-quality photographs and video. There were effective arrangements for ensuring the safe storage and security of written and video records that met guidance issued by the FFLM.

Following each patient’s examination, staff shared information with other health professionals such as GPs, the ChISVA service, and mental health and counselling services. We noted detailed referrals made to sexual health services for follow-up and for STI screening for patients aged 13 and over. This ensured health partners could provide appropriate support to children following their visit to the SARC and to deliver safe care and treatment.

Safe and appropriate use of medicines

The provider had a standard operating procedure (SOP) for the management of medicines. This SOP was adapted for the children and young persons’ service to take account of the responsibilities of G4S at all four sites to maintain medicines stock and monitor the storage facilities (reported on separately for the service provided by G4S). G4S provided assurances about medicine safety to MHL as part of the regular dialogue between the MHL and G4S centre managers and the joint contract meetings.

The FMEs prescribed medicines at the non-recent clinics at Walsall, Bransford, Stoke and Nuneaton, although this was not common due to the nature of the clinic. The FNEs at Walsall who saw patients aged 13 who reported recent abuse issued emergency contraception, PEPSE and Hepatitis B vaccine. These were issued according to need under a patient group direction (PGD) updated in August 2020. A PGD is a written instruction for the supply or administration of medicines to groups of patients who may not be individually identified before presentation.

Track record on safety

The provider had responded well to mitigate risks to patients arising from the COVID-19 pandemic. Leaders had devised a COVID-19 business continuity plan that identified specific areas of their work that the virus had an impact upon. This included risks to the health of staff who might become infected and potential risks to patient safety due to reductions in staffing or the need to interrupt the service. This identified a need to reduce the number of people in the SARC at any one time. The provider had modified the initial assessment pathway to incorporate some remote assessment to limit the time patients spent on site. Staff also remotely assessed all patients for the risks of COVID-19 before coming into the relevant site to be seen.

The provider supported staff to stay safe and protected them from risks from the workplace through a flu and hepatitis B vaccination programme and through a lone-working risk assessment.

The centre manager had conducted a range of audits at the Walsall site, such as an infection control audit, a medical devices audit and an information governance audit. These were part of the provider’s annual programme of audits designed to ensure the service was safe for patients and staff and were used to inform the ongoing dialogue between MHL and G4S.

Lessons learned and improvements

The service learned and made improvements when things went wrong but also learned from things that went well. The provider used an incident reporting, investigation and learning programme known as ‘positive, adverse and irregular events reports’ (PAIER). The provider recorded all PAIERs on a log that enabled them to properly track actions arising and with an identified senior staff member responsible for implementing changes or improvements. A traffic light grading system in the log showed when actions were in progress or had been completed.

All staff had a duty to complete a PAIER whenever an incident or event occurred which required further oversight, regardless of whether the event was significant or seemingly more minor. The log showed that all staff groups, including FNEs, FMEs, the centre manager and senior leaders had made reports since March 2020. Reports also emanated from within the SARC or from external agencies or families. They included positive feedback for individual staff members as well as issues for improvement for either the SARC or for partner organisations.

The provider’s medical director scrutinised all PAIERs to ensure they took appropriate action and that they properly communicated lessons learned to staff.


Enforcement action

Updated 15 March 2021

Effective needs assessment, care and treatment

FMEs and FNEs used a template, based on a proforma recommended by the FFLM, to guide them through the assessment of patients and for recording their findings by way of contemporaneous notes. This was known as the ‘MHL Child and Young Person (Under 18) Proforma’ (the proforma). We reviewed the records for eight children who had visited the SARC.

Staff appropriately assessed patients’ health needs arising from exposure to unprotected sexual activity. These processes were in line with guidelines issued by the British Association of Sexual Health and HIV (BASHH) and the Faculty of Sexual and Reproductive Healthcare (FSRH).

There was a comprehensive pathway for STI screening for patients under 13 and for assessing the need to refer older children to GUM services. This showed that, in respect of sexual health, patients’ needs were accurately assessed, and that staff took appropriate action to ensure they received treatment in a timely way.

However, there were inconsistencies in the way patients’ health histories and health needs were explored by both FMEs and FNEs who conducted their examinations. These fell short of the expected quality standards in relation to undertaking and documenting a comprehensive assessment set out in the following relevant guidelines and service specification.

  • ‘Service specification for the clinical evaluation of children and young people who may have been sexually abused’; September 2015; issued jointly by the Royal College of Paediatrics and Child Health (RCPCH) and the FFLM.
  • ’Guidelines on paediatric forensic examinations in relation to possible child sexual abuse’: October 2015; issued by the FFLM.

These guidance documents stipulate that assessments should be comprehensive and should include a full, paediatric general and ano-genital examination. They require the documented assessment to consider the child’s physical, developmental and emotional well-being against the background of any relevant medical, family or social history.

Where the documented assessment relied upon the observations of the examiner during the physical examination, we noted good use of body mapping in all eight records we reviewed, alongside clear handwritten descriptive information about marks and bruises.

However, in those areas of the documented assessments that related to health and development we saw that there were some sections that were left blank or struck-through. This included those sections set aside for the additional contributions of the patient or their parents or carers. Whilst the extent of this varied from record to record, there was consistently insufficient information in those sections to indicate whether questions about different aspects of their health and development had been explored fully.

We have used our enforcement powers and issued MHL with a warning notice requiring them to become compliant with Regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 05 March 2021.

Monitoring care and treatment

The provider routinely sought feedback from patients, their parents or carers and other professionals. Comments that were both positive or adverse were treated as a PAEIR and used to direct improvements. For example, feedback from ambulance staff and the emergency department of a hospital in relation to confusion about the referral pathways had resulted in an invitation to a stakeholder event to promote the SARC and share information about the pathway.

Staff took part in a range of quality improvement initiatives to improve effectiveness and the provider logged these as part of their assurance processes. For example, when MHL began to provide this service in the West Midlands area, they found that local safeguarding partners did not routinely invite them to strategy discussions. This meant that initial decisions about the timing and appropriateness of children’s sexual abuse examinations were often made without the benefit of clinical insight. In response, MHL employed a safeguarding and strategy manager to improve contact with local partners and promote understanding about the value of having a clinician present to support planning. The provider monitored attendances at strategy meetings month by month. The most recent data showed that there had been a significant increase in the frequency of strategy meeting attendances over the course of 2020.

Staff at The Horizon SARC participated in peer review. One of the provider’s senior medical team reviewed a sample of their video records of their examinations of children. The frequency and number of cases that were reviewed in this way met national guidance although we were not assured that the process was always effective as we have outlined in ‘well-led’ below.

Effective staffing

NHS England have commissioned MHL to provide a skill-mix service for different categories of patients who use the service. Most patients aged 13 and over who reported recent sexual assault were seen through a nurse-led pathway whereas all other children were seen by FMEs. MHL have taken steps to provide a range of training and development opportunities for all clinical staff and to increase the competence of their nursing team.

Doctors working in SARCs are required by the FFLM to comply with the ‘Quality Standards for Doctors Undertaking Paediatric Sexual Offences Medicine (PSOM)’.

There were 11 FMEs on the rota for this service, nine of whom were trained paediatric forensic physicians with two undergoing training. All the FMEs had a wide range of previous experience in relevant roles. The provider had enabled each of the FMEs to undergo specialist PSOM training, provided externally, over the course of the previous several years with six of the FMEs being members of the FFLM.

There is currently no equivalent of these Quality Standards for nurses. However, we are aware that the FFLM and the RCPCH are working with the Royal College of Nursing and NHS England to develop a competency framework for nurses who examine children that report sexual assault.

At The Horizon SARC there were five nurses in the FNE team. One nurse had extensive experience of this work whilst the provider had recruited four others through the early part of 2020 specifically to staff this centre. The nurses had a range of pre-existing relevant skills, qualifications and experience at senior and specialist nursing roles prior to working at the SARC.

The provider had set out an extensive induction and development programme for FNEs that included a range of specialist training modules related to their work. This training was delivered in-house by the provider’s senior team. All FNEs had received most of this training with a small number of modules still to be delivered towards the end of 2020. Nurses told us they felt confident that the training programme had equipped them to carry out their role effectively.

The provider had also developed a comprehensive and structured workplace competence development programme for FNEs. This programme was set out in three-monthly blocks under the mentorship of the provider’s medical director who was responsible for ‘signing-off’ their competence in various aspects of their role and for different types of presentation.

Restrictions arising from the COVID-19 pandemic had meant fewer opportunities for FNEs to undergo face-to-face learning, to test their skills or to gain experience through exposure to live examinations. To overcome this, MHL had staged additional virtual ‘masterclasses’ to ensure nursing staff could acquire specialist knowledge. They had also creatively used simulation training and anatomical models to enable FNEs to practice and demonstrate these skills.

Staff received supervision through scheduled sessions and an on-call system where senior staff provided guidance when needed. The provider’s supervision tracker showed the FNEs had received safeguarding supervision every quarter and monthly operational supervision since April 2020 in accordance with the provider’s policy. The FNEs told us that they were well-supported and welcomed the fact there was always a senior doctor on call whom they could call for advice.

The FMEs took part in clinical supervision sessions with colleagues and they told us they valued the opportunity to discuss their practice. However, we did not see any tracker or other evidence to demonstrate that either operational or safeguarding supervision had taken place for the FMEs.

The peer review process relied on each staff member submitting a request for individual cases to be reviewed to ensure their findings were subject to scrutiny. The provider’s supervision tracker showed that the frequency and number of peer reviews was in accordance with their policy and with national guidance issued by the FFLM. That is, four per year for each examiner.

Co-ordinating care and treatment

Records we reviewed showed that there was effective liaison between the crisis workers employed by G4S and the pathway and support services and sexual offence examiners employed by MHL. Care was co-ordinated by staff from both providers and patients were well-supported as they moved through each part of the pathway.

Staff worked with multi-agency and other health professionals to ensure follow-up care met patients’ needs. In most cases this included information provided to children's social care.

Each patient who visited the SARC was referred onwards, with their consent, to a ChISVA service provided by an external organisation. Similarly, staff routinely referred each child for counselling to a therapy provider as part of the MHL aftercare pathway and this ensured they continued to be supported following their examination.

In every patient’s case we reviewed we noted that clear information had been exchanged with sexual health services to support good continuity of care.

Health improvement and promotion

Records we reviewed showed that, unless patients declined, staff routinely wrote to their GPs so they could receive follow-up health advice in the community.

As part of the aftercare process for patients following their examination, and in addition to making referrals to sexual health services, staff took time to support patients with sexual health advice to ensure they were better enabled to keep themselves safe. This included information about contraception methods and about alcohol or substance use.

There was also a range of information leaflets on display about other local health services.

Consent to care and treatment

Staff understood the importance of seeking informed consent and used a range of supporting written information to help them to communicate with both patients and their parents or carers about the SARC’s processes.

Staff explained that they were aware of the necessity for obtaining consent throughout the patient’s engagement with them. Our review of records showed that this was well-understood and firmly embedded in practice. This included the need to obtain formal written consent from patients and their parents or carers where this was required, as well as ongoing verbal consent as the examination progressed. There were separate consent processes for the use of intimate images and for the sharing of information with external agencies.

Staff were confident in the application of both the ‘Gillick competence’ test and the ‘Fraser guidelines’ for patients under 16, and of the need to involve someone with parental responsibility in decision making in most cases. Staff could also confidently use a mental capacity assessment tool that was embedded into the examination proforma for patients aged 16 and 17 and for parents of patients where there may have been doubts about the parent’s capacity to fully understand.


No action required

Updated 15 March 2021

Kindness, respect and compassion

All the staff we spoke with during the inspection demonstrated an empathetic approach to patients, and staff told us how they placed children at the centre of what they do. We noted that respect and empathy were among the person-centred skills that featured as integral behaviours throughout the training and competency programme.

Staff were knowledgeable about the impact of abuse on children. They were passionate about their work and spoke about their approach to providing care and support to children who had experienced abuse and trauma and at a time when they were particularly vulnerable. One staff member told us they were privileged to be able to care for the children who visited the SARC. Another staff member said they were also aware of the impact of the child’s experience on parents and that it was important to be kind and respectful towards accompanying adults too.

Staff told us that they would ordinarily have wished to spend much more time with patients to build rapport and allow them more time and space to become more comfortable and at ease before their examination began. However, this had been challenging due the predominantly remote assessments that were part of the COVID-19 measures.

Patients would usually have been allowed time to shower and have access to clean clothing and a ‘comfort pack’ (a small selection of toiletries) following their examination. However, the service did not routinely offer this temporarily due to the need to reduce the time they could safely be on site. This was a decision made on a case-by-case basis depending on the patient’s wishes at the time. Patients were offered something to eat or drink following their examination if they wished.

Before the inspection we arranged for comment cards and collection boxes to be placed in a suitable area of each of the sites to invite children using the service, their parents or carers and any visiting professionals to provide us with feedback about their experience. We did not receive any completed comments cards for the period of around 10 days before our visit.

The provider routinely collected feedback from patients and others. Just over 100 people had provided feedback in the period since February 2020. We have reviewed these comments, which showed that patients and carers had been treated kindly and compassionately during their visit.

For example, one patient said that they had felt welcomed and accepted, and that the staff made them (the child) feel like it was not their fault, which motivated them to tell their story.

A parent thanked the service for making their child relaxed at such a difficult time.

Involving people in decisions about care and treatment

As we have set out in 'safe' above, patients aged 13 and over who self-referred were subject of an assessment as to whether they were competent to consent to the examination. Children's social care were notified of the attendance of any child or young person under the age of 18. Forensic samples for patients who self-referred were retained for up to seven years after their examination. This means that patients who self-referred had some control over the outcome of their visit.

The ‘voice of the child’ was evident in most of the eight records we looked at, although this was to a varying degree. For one patient, their wishes and feelings were well represented using ‘I’ statements and it was clear how the child felt about their experience. In two of the records the children’s voices were represented to only a limited degree, and in one record it was not evident at all. This did not consistently demonstrate how well patients were engaged with the assessment and examination and we have told the provider that they should make improvements in this area.

Our review of the feedback collected by the provider was very positive in relation to patients’ involvement in decisions about their care.

One parent said that there was great communication with their child.

One patient said that the staff they had was nice and they did not force them (the child) to do anything they did not want to do.

Privacy and dignity

Staff at The Horizon SARC understood the importance of respecting patients’ privacy and dignity and this was evident in our conversations with them during our visit. It was clear that staff viewed children as people in their own right, with the same needs for privacy as other patients.

Clinicians examined patients with sensitivity given the intrusive nature of the process, only proceeding with each stage once the patient had agreed fully. There were screens in each of the paediatric examination rooms to enable patients to undress in private and at their own pace. Staff helped patients to keep covered those areas of their body that were not being examined.

The feedback collected by the provider also indicated that patients and their parents felt that their privacy was respected.

One patient said that they felt safe.

Another patient said that staff made them (the child) feel very comfortable and they did not feel nervous.


No action required

Updated 15 March 2021

Responding to and meeting people’s needs

Patients could choose the gender of the examining clinician. Although the workforce was mainly female, the provider had male FMEs that could be called upon to carry out the examination when required. We noted that this had happened effectively during our review of records. Patients also had the opportunity to have a chaperone present if they wished. We also saw that this happened for one of the patients when a joint examination took place with two clinical staff members according to the child’s choice at the time.

Each site service was accessible for patients with disabilities or those who used wheelchairs. However, a recent access audit of the Walsall site showed some limitations to accessibility in relation to the car park and the access to the main door of the centre. These issues, along with other issues about the age and suitability of the premises were part of ongoing dialogue with commissioners about potentially relocating to another, more modern facility in due course.

The service used interpreters and a telephone translation service to ensure patients or families whose first language was not English could understand the processes and could give informed consent. The service also had a ‘grab bag’, a set of portable equipment to enable clinicians, on rare occasions, to assess and examine patients at a place other than at the SARC, for example if they were at hospital or unable to get to the SARC due to a disability.

Patients and their parents or carers were given sufficient information about the service and about what to expect during their episode of care. The provider supplied written material to patients and their families and there were specific leaflets for younger children, older children, parents or carers and children with additional communication needs. All the literature we saw was written in a child-focused and informative style using appropriate language. The material emphasised that patients had choices they could make about their care and explained how staff would seek consent.

The provider gave all patients who visited the SARC a booklet entitled ‘Summary of your care’. This contained a range of information, specific to them, about the care they had received at the centre, such as the names of their examiner and crisis worker, the procedures they had undergone and the medication they had been given. The purpose of this was to help them better understand their experience.

There was appropriate, child-friendly décor in each of the sites in the non-clinical areas and a small number of toys. However, these had been temporarily removed to reduce the number of potential contact points and the risk of COVID-19.

Timely access to services

Commissioners had required MHL to provide a 24 hour-a-day service for children who experienced recent sexual assault with a 90 minute call-out time as well as a service for children who reported non-recent abuse. The provider had structured their resources around the hub and spoke model discussed above to meet this requirement. Commissioners advised us that MHL had consistently met the required call-out times throughout the year despite the modifications they had had to make to the assessment process in response to the COVID-19 restrictions.

This service did not yet have a dedicated website. A temporary webpage had been set up, but this was difficult to locate through a web search unless searching on the name of the service itself. The temporary webpage provided limited information about accessing the service and a telephone number but had no information about operating times or the different sites for non-recent allegations. The website for the service operated by G4S from the Walsall site had a link for children and young people, but the telephone number was different to the number displayed on the temporary webpage. Children and young people who used that number would be responded to by the G4S call centre then redirected to the MHL pathway and support service. The provider should make improvements to the online information to ensure children can contact the service directly and in an appropriate timescale.

Listening to and learning from concerns and complaints

The provider had a complaints policy and displayed information in the SARC about how to complain to both MHL and to NHS England. Complaints were logged, acknowledged within two days of receipt and responded to formally within 15 days. Only two complaints had been received over the course of 2020, both of a relatively minor nature and both had been resolved satisfactorily with learning points communicated to staff.

The provider also responded to suggestions made by patients or their families. We noted a log of ‘you said we did’ actions that the provider had carried out in response to feedback and complaints. For example, a speaker had been purchased for the examination room to enable children to listen to music in response to feedback that it was too quiet, and a range of alternative foods had been bought for people who had certain intolerances.


Enforcement action

Updated 15 March 2021

Leadership capacity and capability

Mountain Healthcare Limited provide forensic medical and criminal justice services in different parts of the country, including SARCs. Our discussions with leaders and review of strategic and policy documentation, showed the senior team understood this field of health care.

A number of the senior clinical staff represented the provider on key national bodies such as the FFLM. The provider was also recognised as an approved education centre by Health Education West Midlands. For example, they had recently received approval to host medical educational placements at the Horizon SARC for community paediatricians from Birmingham Community Healthcare NHS Foundation Trust.

Leaders were highly visible, with staff reporting that they could call any member of the senior clinical team to seek advice or guidance. One FNE we spoke with said they felt the provider was very focused on supporting staff.

Vision and strategy

Staff told us that they fully embraced MHL’s vision of ‘providing the best possible standard of care for vulnerable people’ and used it to drive their approach to providing person-centred care.

MHL had a clear set of key strategic objectives for each year, the progress of which were monitored and reported on. The annual Governance report for 2019 showed that they had achieved their three objectives of ‘Making organisational learning visible’, ‘Improving our user experience for e-learning’ and ‘Making staffing our priority’. The latter objective included the roll-out of the provider’s own leadership and management academy through the course of 2020.


Staff told us that MHL was a positive employer to work for and that they felt highly valued as individuals. Staff reported that it had been particularly challenging through the course of 2020 but that they had been very pleased with the way MHL had supported them to fulfil their role. It was clear that staff development and well-being had been prioritised in line with the provider’s strategy.

Governance and management

The provider operated an integrated governance model that enabled communication and decision making about different parts of their business to be coordinated by one executive group. The integrated governance board had overall accountability to the executive board for oversight of the organisation’s key work areas. Sub-groups for information governance, decision making, safeguarding, medicines management and risk management, each headed by a member of the senior team, contributed to the main group.

A series of governance frameworks supported these groups, including the paediatric governance framework. The paediatric governance group met quarterly and considered risks, quality initiatives, PAIERs and audits from each of the MHL locations that provided a paediatric service, including The Horizon SARC. This meant that there was a line of accountability to the executive board for issues that occurred in the West Midlands service.

Operational governance processes, however, had not always been effective in identifying shortfalls in performance or quality. For example, there was a daily and weekly case review process that included oversight of each of the patients’ records by an identified doctor (the on-call FME) where available. In all eight of the records we examined, an identified doctor had not been available or involved in the review. Whilst the case review process satisfactorily checked that follow-up actions were completed, it had not identified shortfalls in safeguarding practice and in the quality and extent of assessment information we outlined in ‘safe’ and ‘effective’ above.

Staff received scheduled supervision sessions in accordance with the provider’s policy. Staff also submitted cases for peer review by a senior doctor, but this consisted solely of a review of the DVD of the examination to see if the reviewer agreed with the examiner’s findings. The peer reviews did not routinely include a review of the records or a reflective discussion with the relevant examiner to explore how they had arrived at their conclusions. In which case the supervision and peer review process had also not identified the shortfalls in practice we had noted.

Inspections of the provider’s other locations had shown areas for improvement in relation to safeguarding practice. The shortfalls in professional curiosity about safeguarding risks had featured in an earlier inspection. The provider’s safeguarding committee had addressed these issues through the promotion of professional curiosity in staff training. Despite this, we found evidence of shortfalls in this area of practice during our review of children’s records and our discussions with the centre manager and the registered manager. This means that the provider had not evaluated whether the steps they had taken through their safeguarding committee had been effective in enabling staff to identify and mitigate risks.

The provider had a risk register that was used to address organisational and service risks that was overseen by the senior team and shared with commissioners. The risk register showed a number of identified risks with an assessment of their seriousness based on the likelihood and impact on the service or on children using the service. Each risk had a clearly defined outcome, with clear direction and accountability. However, the risks in relation to safeguarding performance had not been identified on the register and actions to address them were not overseen by the provider’s senior team. This meant that the provider’s actions, or the need to commit resources to mitigate these risks were not directed by a strategic risk plan that could be shared with commissioners.

Due to these shortfalls we have used our enforcement powers and issued MHL with a warning notice requiring them to become compliant with Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 05 March 2021.

Appropriate and accurate information

The provider collected data on their performance as specified in the NHS England commissioning framework for these types of service. The provider shared quarterly performance data with NHS England along with information about the MHL audit programme and all information about the PAIERs. This enabled commissioners to be well-sighted on the provider’s monitoring and improvement activity. Commissioners advised us that they were fully confident in the provider’s assurance processes.

The provider was efficient at collecting and analysing data about its services. Information was accurate and enabled the provider to have an overview of its performance. The data set showed that MHL had a good understanding of the prevalence of sexual assault on children and young people in the West Midlands area as compared with other areas that they operate within. This enabled them to commit appropriate staffing levels to the service.

Engagement with clients, the public, staff and external partners

The provider actively sought feedback from patients, their parents or carers and other professionals at the time they attended the SARC with the purpose of learning from this. We have reported some of this feedback in ‘caring’ and ‘responsive’ above.

MHL used a variety of communication methods, such as team meetings and a newsletter, to report the outcomes of PAIERS and inform staff about changes. This meant that staff supported changes and understood their role in relation to practice improvement. This also ensured staff in all their SARCs understood the provider’s purpose and direction and had the opportunity to contribute. An annual staff survey was part of this engagement and the provider planned to move to a ‘pulse’ style staff survey to gauge their perceptions more frequently.

Staff undertook a range of outreach activities to promote the SARC and raise its profile locally. The manager kept a log of all this activity; there had been twelve such events since February 2020 which included engagement and presentation to local domestic abuse organisations, exploitation groups, Walsall college and Warwickshire police training. Much of this had been done remotely due to COVID-19 restrictions.

Continuous improvement and innovation

Staff were encouraged to take part in quality improvement initiatives. In particular, each FNE was allocated a ‘champion’ role with the purpose of increasing the profile of the SARC locally and promoting the service. These roles included trafficking, substance misuse, domestic abuse and A&E, each with corresponding outreach activity and engagement with local services and agencies.