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The Glade Sexual Assault Referral Centre-Telford

Inspection Summary


Overall summary & rating

Updated 2 October 2020

We carried out a focused desk based review of healthcare services provided by G4S at the Glade SARC, Telford in June 2020.

The purpose of this review was to determine if the healthcare services provided by G4S were now meeting the legal requirements and regulations under Section 60 of the Health and Social Care Act 2008. We found that improvements had been made and the provider was no longer in breach of the regulations.

We do not currently rate the services provided in sexual assault referral centres.

During this desk based review we looked at the following questions:

Are services well-led?

Background:

In Telford, services for the support and examination of people who have experienced sexual assault are commissioned by NHS England and West Mercia Police. The contract for the provision of sexual assault referral centre services in Telford for adults over 18 years of age, is held by G4S. G4S is registered with CQC to provide the regulated activities of diagnostic and screening procedures, and treatment of disease, disorder or injury.

The Glade is located in Telford. The centre is not always manned, with staff attending only when required. The administrative support was carried out at the Worcester SARC.

We last inspected the service in May 2019 when we judged that G4S was in breach of CQC regulations. We issued a requirement notice on 3 January 2020 in relation to Regulation 17, Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The report on the May 2019 inspection can be found on our website :

https://www.cqc.org.uk/location/1-877389019/reports

This desk based review was conducted by a CQC children’s services inspector and included a review of evidence and a telephone conversation with the SARC manager.

Before this review we reviewed the action plan submitted by G4S to demonstrate how they would achieve compliance and a range of documents submitted by G4S.

Documents we reviewed included:

  • Safeguarding audit form spreadsheet 2019-20
  • New Confidential Medical Aftercare Form Version 11 Amended March 2020
  • Team meeting minutes 2020
  • Safeguarding Referrals, Alerts and Outcomes Spreadsheet 2019-20
  • Safeguarding Audit Learning emails 2020

We did not visit The Glade to carry out an inspection because we were able to gain sufficient assurance through the documentary evidence provided and a telephone call.

At this inspection we found:

  • The provider had amended the confidential aftercare form to include a holistic safeguarding assessment that included questions about substance misuse.
  • The amended form also had a dedicated section to record mental capacity assessments. This had not been audited at the time of the review because so few patients had accessed the service during the pandemic.

  • The provider had implemented effective safeguarding audit processes.
  • The provider had identified ways to share the safeguarding audits with staff to ensure continuous learning.
  • The provider had shared learning with other locations.

Inspection areas

Safe

Updated 2 October 2020

Effective

Updated 2 October 2020

Caring

Updated 2 October 2020

Responsive

Updated 2 October 2020

Well-led

No action required

Updated 2 October 2020

At our last inspection we found there were ineffective systems to manage safeguarding risks. Additionally, there was a lack of evidence regarding effective processes to monitor the mental health of a patient.

These are the areas reviewed during this desk based review:

Governance and Management

The provider had reviewed safeguarding systems and processes to monitor the mental health of a patient. These included:

  • All patient records were reviewed within 24 hours by the SARC co-ordinator to ensure timely follow up of safeguarding actions. Missed opportunities were escalated to the SARC manager and when appropriate, a safeguarding referral was made.
  • The provider had integrated a safeguarding audit process into the existing audit cycle. One to ones, team meetings and email updates were used to disseminate learning as a result of audit. This provided opportunities for individual and team learning.
  • An audit of the new safeguarding form gave the provider assurance that safeguarding processes were being followed and appropriate actions were being taken by staff to keep patients safe. Staff were escalating concerns appropriately and findings from the audits were shared to improve practice. Learning from the safeguarding audit had also been shared at the team meeting to support all staff in improving safeguarding practices.
  • Safeguarding was a standing agenda item at team meetings. This was allowing the provider to share audit findings, documentation changes and identify and share learning from training.
  • The updated confidential medical form increased the opportunity to holistically identify any unmet mental health or substance misuse needs. We had identified this as an area for improvement at the initial inspection.
  • Improved communication between the SARC manager and clinical lead supported consistent assessment of patients’ mental health and capacity. The clinical lead regularly audited a sample of records of each of the Sexual Offence Examiners (SOE). The SARC manager raised with the clinical lead any issues regarding recording of mental health and capacity assessments so that feedback was given to practitioners to improve practice.

Quality of mental health assessments were discussed at team meetings to identify training and share learning. The SARC had made arrangements with a local mental health provider to access further training.

In order to support continued staff learning and provide assurance during the pandemic, learning opportunities have been available remotely.