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The Glade Sexual Assault Referral Centre-Telford

Reports


Inspection carried out on No visit - desk based review

During an inspection looking at part of the service

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 carried out on 14 May 2019

During a routine inspection

Summary findings

We carried out this announced inspection on 14 May 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 led by a CQC inspector who was supported by a second CQC inspector.

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.

Background

The Glade Sexual Assault Referral Centre (SARC)Telford provides a service of care to women and men who have allegedly been raped or sexually assaulted in West Mercia; Worcestershire, Herefordshire and Shropshire, Telford and Wrekin. The services are commissioned by NHS England and West Mercia Police.

The Glade SARC Telford provides services to adults (over 18 years of age). West Midlands Paediatric Service, led by Birmingham Community Healthcare in partnership with several other trusts and organisations, provide the service to anyone under 18. Young people aged 16 and 17 years old can choose to access The Glade instead of the regional paediatric services if appropriate.

The SARC is located within a quiet area in a housing estate within its own secure gated grounds. There are two separate buildings with level access for people who use wheelchairs. The SARC has its own car parking and the signage is discrete. The entrance is welcoming, with CCTV for added security. The entrance to the SARC is accessed by key and security code which prevents the general public from accessing the centre unauthorised. A clear record is maintained of all visitors.

The staff team consists of full-time and flexible staff that provide cover both day and night. Permanent staff include a centre manager, a coordinator (who is a crisis worker) along with two nurses and a midwife who are sexual offence examiners. Flexible staff are staff who work an on-call rota, to cover daytime, nights and weekends and include examiners and crisis workers.

The service is provided by G4S Health Services (UK) Limited (G4S) and as a condition of registration 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 Glade SARC – Telford is also the SARC manager.

The centre is not always manned with staff attending only when required. All the administration is carried out at the Worcester SARC. All requests and referrals to the Glade SARC are managed through a call centre run by G4S, who liaise with examiners and crisis workers to ensure appointments meet the needs of patients and are within forensic examination timescales.

On the day of inspection, we spoke with four staff including the registered manager, the coordinator, a sexual offence examiner and a crisis worker. We looked at the records of nine patients. We left comment cards at the location in the two weeks prior to our visit but received no responses from people who had used the service in that period. We looked at policies and procedures and other documentation about how the service is managed.

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.

Our key findings were:

  • The service had systems in place to manage risk but some were not effective.
  • Safeguarding procedures were inconsistent.
  • Staff did not always adequately document the mental capacity of patients.
  • Records were not always completed in a consistent manner and the voice of the patient was not always apparent.
  • The service had thorough staff recruitment procedures.
  • 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 patients’ needs.
  • The service had effective leadership and culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The service asked staff and patients for feedback about the services they provided.
  • The service staff dealt with complaints positively and efficiently.
  • The staff had suitable information governance arrangements.
  • The service appeared clean and well maintained.
  • The staff had infection control procedures which reflected published guidance.

We identified regulations the provider was not meeting. They must:

  • Carry out safeguarding audits to improve the assessment of risks.
  • Carry out audits to improve the quality of mental health and mental capacity assessments.

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

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

  • Record safeguarding issues arising from substance misuse.