Updated 17 May 2021
Summary findings
We carried out this announced inspection on 16 and 17 February 2021 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. Two CQC inspectors, supported remotely by a specialist professional advisor, carried out this inspection.
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?
Are services safe?
We found that this service was providing safe care in accordance with the relevant regulations.
Are services effective?
We found that this service was providing effective care in accordance with the relevant regulations.
Are services caring?
We found that this service was providing caring services in accordance with the relevant regulations.
Are services responsive to people’s needs?
We found that this service was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found that this service was providing well-led care in accordance with the relevant regulations.
Background
The Hazlehurst Centre is a sexual assault referral centre (SARC). The centre provides health services and forensic medical examinations to people of any age, in West Yorkshire who have experienced sexual violence or sexual assault. The centre occupies two floors of a new building, situated in a business park in Morley, Leeds. The building has a secure carpark accessed via an intercom system. Staff protect patient’s privacy when they enter the SARC by greeting all visitors at the dedicated SARC entrance. The building has lifts and therefore offers some accessibility to people with limited mobility. All patients’ mobility needs were screened before they were given an appointment at the SARC. If required, patients can be seen at home or will be offered an appointment at an accessible SARC suite elsewhere in the region.
The adult SARC is located on the first floor and has two forensic examination suites, a kitchen, patient waiting room, staff shower rooms, toilets and staff offices. The paediatric suite mirrors this on the second floor, however for health and safety reasons the kitchen is used by staff only.
The Hazlehurst Centre is jointly commissioned by NHS England and the Police and Crime Commissioners across Yorkshire and Humberside. Adult services are available 24 hours a day, seven days a week by appointment to people of any gender, aged 16 and over. Patients can self-refer or attend via a police referral. The paediatric service is available to children and young people of any gender, age 0-15. This service operates during the day, seven days a week. Referrals into the paediatric service must be made by a professional, however should a young person contact the SARC, staff will ensure help is arranged and a strict safeguarding protocol is followed. The paediatric SARC also provides a clinic during the week, for children and young people, who have suffered alleged historical sexual abuse.
The Hazlehurst Centre has a centre manager who has responsibility for the adult and paediatric suites. The adult SARC staff team includes forensic nurse examiners, crisis workers and administration staff. The paediatric SARC staff team includes a paediatric service lead, a specialist sexual health nurse advisor, a strategy coordinator, forensic medical examiners, crisis workers and administration staff. Every patient attending the SARC is offered a referral to an Independent Sexual Violence Advisor (ISVA) or Children and Young People’s Independent Sexual Violence Advisor (CHISVA) depending on their age. These services, however, were offered by another provider and were therefore not part of this inspection.
The service is provided by a limited company 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 Hazlehurst Centre was the centre manager. Mountain Healthcare Limited’s medical director and associate medical director were members of the Faculty of Forensic and Legal Medicine.
Social distancing measures were in force at this time of this inspection; therefore, we conducted some interviews virtually and two inspectors visited the centre for one day. During the inspection we spoke with 12 staff members. We were unable to speak to any patients during the inspection. Throughout this report we have used the term ‘patients’ to describe people, including children, who use the service to reflect our inspection of the clinical aspects of the SARC.
We looked at policies and procedures and other records about how the service is managed.
Our key findings were:
- The service had systems to help them manage risk.
- The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
- The service had thorough staff recruitment procedures.
- Staff knew how to deal with emergencies. Appropriate medicines and 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 clients’ needs.
- The service had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked well as a team.
- The service asked staff and clients 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