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Alder Hey Children's Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 19 April 2021

We carried out this announced inspection of the Rainbow Centre children’s sexual assault service over two days on 9 and 10 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 inspectors supported by a specialist professional advisor, carried out the inspection. To reduce risks presented by Covid-19, we used a combination of remote and face to face interviews.

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 Rainbow Centre children’s sexual assault referral centre (SARC) is provided by Alder Hey Children’s NHS Foundation Trust. The Rainbow Centre provides co-ordination for all safeguarding activity across the trust. The children’s SARC is part of the trust’s Rainbow Centre safeguarding hub. Access to the Rainbow Centre is via a discreet entrance on the ground floor next to the Emergency Department.

NHS England and Improvement (NHSE/I) commission the children’s SARC with a financial contribution from Merseyside Police. NHSE/I are the main commissioners who manage the contract although the police commissioners are part of contract monitoring discussions. The Rainbow Centre Children’s SARC sees children and young people up to the age of 16 years. In addition, they see young people between 16 to 18 years if they have additional needs that would make Rainbow SARC the best place for them to be seen. The SARC sees patients who have experienced or are suspected of having experienced recent sexual abuse (up to 21 days previously) and non-recent sexual abuse (occurring outside that timeframe). An assessment is made for each referral. The service provides forensic medical examinations and related health services to children and young people from Liverpool, Sefton, Knowsley, St. Helens and Wirral who have been sexually abused. Alder Hey is also a tertiary centre therefore they sometimes see children from the wider North West region. For example, patients who have accessed another service in the hospital and then need access to a SARC. The service is also commissioned to provide a psychology service to children and young people who access the SARC. The psychology service was not in the scope of this inspection.

The SARC service is available 24 hours each day although children and young people are rarely seen out of standard working hours. Access to the SARC is by police or social worker referral only. The forensic examinations are carried out by two doctors. The Forensic Medical Examiner (FME) and a paediatric doctor. The FMEs are provided by St Mary’s SARC, Manchester University Foundation Trust (MUFT) from the St Mary’s Merseyside adult SARC rota. The paediatric doctors are provided by Alder Hey Children’s NHS Foundation Trust. There is a safeguarding consultant paediatrician on call to support the paediatric doctors until midnight. There are two specialist safeguarding nurses provided by Alder Hey who have recently completed forensic nurse specialist training. They offer patients sexual health follow up at Alder Hey two days-a-week. Health care assistants provided by Alder Hey deliver the role of crisis support workers. There are two administrators at the Rainbow Centre who support the work of the SARC.

The service referred patients for follow up to local independent sexual violence advocacy services (ISVA).

Alder Hey Children’s NHS Foundation Trust is responsible for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

The lead clinician has completed the Faculty of Forensic and Legal Medicine examinations and is on the General Medical Councils (GMC) specialist register for Clinical Forensic and Legal Medicine. The FME’s covering the rota for the SARC have a range of specialist qualifications including Forensic and Medical Examinations in Rape and Sexual Assault (FMERSA) training and some had obtained or are working towards FFLM membership.

During the inspection we spoke with nine staff. No patients accessed the SARC during the time that we were on site.

We looked at policies and procedures and other records about how the service is managed.

Throughout this report we have used the term ‘patients’ to describe children and young people who use the service to reflect our inspection of the clinical aspects of the SARC.

Our key findings were:

  • The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The staff worked collaboratively to provide a child focused, holistic service and to reduce risks to children and young people.
  • The service had systems that helped them manage risk.
  • There were processes for monitoring the standard and quality of care.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • 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.
  • The appointment/referral system met patients’ 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 patients for feedback about the services they provided.
  • The service had suitable information governance arrangements.
  • The service appeared clean and well maintained.
  • The service had infection control procedures that staff followed and which reflected published guidance.

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

  • Identify effective processes to regularly review the partnership agreement for MUFT staff.
  • Complete checks to ensure that processes for securing Disclosure and Barring Service (DBS) renewals are effective
  • Develop an effective way to record FME’s local induction.
  • Advise patients of the gender of the examining staff and offer a choice of gender where possible.
  • Provide visible and accessible information to patients to help them to feedback and or make complaints about the service.
  • Obtain a fridge thermometer that alerts staff if the temperature in the fridge has gone above or below the recommended levels between checks.
Inspection areas

Safe

No action required

Updated 19 April 2021

Safety systems and processes (including staff)

Our review of the SARC’s policies, interviews with staff and patient record reviews showed that the Rainbow Centre had systems and processes to ensure patients were safe. Policies relating to safe care and treatment were up to date and regularly reviewed.

As stated in the trust’s policies, staff were trained in topics relating to safe practice such as health and safety, resuscitation and infection control. Staff’s knowledge and skills were refreshed according to the trust’s training schedules. There was effective oversight of training compliance through the trust’s reporting systems.

Staff were also able to access additional training to support with Continuing Professional Development (CPD); for example, report writing and court attendance training. We saw the positive impact of this in the reports that we looked at as part of our record review.

Staff received training in safeguarding both adults and children that met level three of national intercollegiate guidance for healthcare staff. Due to the Covid-19 pandemic some of this training had to be delivered online. However, the trust had started to deliver some face to face level three children’s safeguarding training to small groups of staff. It was evident through our record review, that staff were aware of safeguarding factors and articulated and analysed these in referrals and reports. For example, staff identified adverse childhood experiences that may make children and young people more vulnerable.

All referrals to the SARC were via the police or a social worker. This was in accordance with the local multi-agency Child Sexual Abuse (CSA) pathway. Self referrals were not accepted.

There were flags on the electronic patient record that alerted staff to identified vulnerabilities. For example, if a child had attended the SARC previously. We saw from our review of the records how this influenced the staff’s response including using local escalation procedures for a patient who had attended the SARC on multiple occasions. This meant that decisions about the safety of children and young people were made jointly with the most up to date information.

The trust had clear recruitment processes and all staff were subject to enhanced DBS checks at recruitment. However, they had not been updated every three years as identified in Alder Hey’s Recruitment and Selection Policy. In addition, MUFT’s recruitment policy did not require staff to have a regular DBS renewal and this issue had not been identified because the partnership agreement had not been reviewed. This means that the SARC could not be assured that staff were subject to appropriate ongoing checks to ensure they were safe to deliver care and treatment to vulnerable patients. This issue was identified during the inspection and raised with leaders. Leaders responded swiftly to mitigate immediate risk. They put processes in place to ensure that all staff employed to provide a service at the SARC were subject to regular reviews, including those staff not directly employed by the trust.

Risks to patients

Staff assessed patients for a range of risks or additional factors that may make them more vulnerable. This included mental ill health, sleep routines, substance misuse, child sexual exploitation, special educational needs and/or disabilities and adverse childhood experiences. We saw from our record that this important information at the initial assessment resulted in health action plans to meet unmet needs. This meant referrals were made to other agencies such as local substance misuse services, to the in-house psychologist, dentists and school nurses.

If a child became looked after by the local authority within three months of the examination at the SARC, the assessment report was used for an initial health assessment. This reduced the times that vulnerable children and young people were assessed and examined and ensured the service was child focused. We also saw examples of when it was appropriate to repeat an assessment when a particularly vulnerable patient became looked after. This meant that assessments were always conducted to provide good outcomes for the patient and were led by children’s individual needs.

Staff took action to address risk of harm to patient’s physical health. This included an assessment for the need for post-exposure prophylaxis after sexual exposure (PEPSE) and the need for emergency contraception and sexual health screening. Patients were seen at the SARC for follow up sexual health screening that was offered by the nurses. This meant the patient’s holistic needs could continue to be met as they were being seen in the same place with the same set of records.

All spaces in the SARC had been subject to an environmental risk assessment. This had recently been undertaken for the first time. It was seen to be comprehensive and had been completed in partnership with a clinical lead from the child and adolescent mental health (CAMH) service. The risk assessment was thorough, took account of low-level risks and justified the reasons for considering risks. This meant that staff could mitigate risk and be more alert when vulnerable patients accessed the SARC. Patients were supervised by staff members throughout their time in the SARC. The initial holistic assessment identified if there were increased risks to the young person being alone and supervision was adjusted accordingly; for example, when using the bathroom.

Premises and equipment

Staff followed infection control processes to prevent patients and staff from acquiring healthcare-associate infections. Due to the Covid-19 pandemic, the SARC staff had removed all posters and toys to reduce the risk of transmission. The SARC lead had oversight of the outcome of cleaning audits and we saw that non-compliance was followed up with the trust audit team and staff. Clinical waste and sharps were disposed of safely according to the trust’s schedules and policies. The SARC used a healthcare inspection tool to be assured that they were meeting expected standards for cleaning, control of substances hazardous to health (COSHH), waste disposal, management of the environment and whether the service was displaying the results of their last infection prevention control audit. This allowed all staff members to take responsibility for any areas of concern.

The forensic examination room was stringently cleaned after use to prevent the cross-contamination of contact evidence. The cleaning and checking met guidance issued by the Faculty of Forensic and Legal Medicine (FFLM) and the Forensic Science Regulator’s standard. Access to the room was by swipe card only. SARC leaders could identify through trust processes who had accessed the forensic examination room.

Staff confirmed they had been trained in DNA cross-contamination, infection control and a level of life support training aligned to their role. Log books with clear signature sheets provided assurance that regular checks were taking place. The signature sheets meant that SARC leaders could identify staff and audit these processes. All equipment in the SARC had been subject to regular testing so staff were assured that it was safe to use.

The medical staff conducting the examination decided who was going to be the responsible colposcope technician (a colposcope is a piece of specialist equipment for making records of intimate images during examinations, including high-quality photographs). Both MUFT and The Rainbow Centre SARC provided training on induction on how to use the colposcope effectively. For the MUFT FMEs, the SARC was responsible for providing local training. We saw evidence of the training during our inspection which included reiterating local practices to ensure that images were securely saved. This meant that FMEs were reminded about local procedures which reduced the risk of errors occurring.

The SARC adhered to trust policies to manage waste and hazardous substances. These policies were kept in locked cupboards. There was a clear record of flushing logs to mitigate the risk of legionella. This meant that local and trust leaders were able to audit the process.

Information to deliver safe care and treatment

Staff used standard forms to help in asking the right questions when assessing and examining patients. In our review of records, we saw good use of body maps to document marks and injuries and assessment forms that helped staff to consider general wellbeing such as sleep. The use of standardised forms ensured staff asked relevant questions which provided an individualised comprehensive assessment.

Most records were clear, legible and accountable. When staff recorded in paper records, we saw that individual sheets were signed which made it clear what factors staff members had considered as part of their assessment. Record keeping standards had improved through audit. An audit of the FME records in 2019 and a subsequent re-audit clearly demonstrated an improvement in record keeping practice.

The single electronic record system meant that relevant information could be accessed if a patient had used another service in the trust or the SARC previously. There was also an area in the records for highly sensitive information. This allowed staff in the SARC and the wider trust to be alert to and respond to safeguarding concerns.

Safe and appropriate use of medicines

All medicines in use at the SARC were individually prescribed for each patient by one of the examining doctors. The SARC did not stock controlled drugs.

The SARC stocked emergency contraception and hepatitis B vaccinations. Other medications were accessed through the trust’s pharmacy as required.

We saw that emergency contraception was stored in a locked cupboard with appropriate stock level checks and the trust pharmacy also completed stock checks. The medication log book was updated accordingly when medication was administered. This meant there was a clear audit trail for medication administered at the SARC.

Vaccinations that were temperature sensitive were stored in the fridge. Fridge temperatures were monitored daily to ensure medicines remained safe. The fridge plug had recently been labelled after a daily check identified it had been accidentally unplugged. We saw that this had been dealt with appropriately and the medications disposed of as well as reporting the incident according to Alder Hey’s incident policy. The SARC did not have access to a fridge thermometer that assured staff that recommended temperatures had been maintained in between daily checks. This would provide staff with reassurance that appropriate temperatures had been maintained and vaccinations were viable.

Track record on safety

The SARC leaders had a good understanding of their performance. We saw examples of leaders proactively managing mandatory training to ensure that all staff were up to date.

The SARC used a programme of checks and audits to monitor safety practices. These included infection control checks and audits and medication checks. Clear records were kept of the daily and weekly checking activities and we saw how the SARC manager responded to anything of concern. This ensured the site operated safely.

Staff told us they knew how to report incidents. We saw that leaders had responded effectively to incidents reported and we noted several examples of how this had led to improved practice. For example, a record keeping audit following an incident had led to improvements in the way consent was recorded by FME’s. We also saw that leaders had improved safety for various functions by developing or amending standard operating procedures (SOP) following incidents.

The Rainbow Centre SARC risk register was regularly reviewed, updated and managed. This showed that staff were responsive when risk was identified.

Lessons learned and improvements

The process for reporting incidents was robust. All incidents were reported on the trust’s electronic system and were assessed to determine the timescale for investigation and response. The service learned and made improvements from incidents. Themes from incidents were reviewed and reported through the quarterly assurance and performance review. Leaders and staff regarded the incident reporting process and the frequency of reporting as a positive feature. This showed an open culture to learning from adverse events.

The trust collected feedback from patients and families about the service and very few comments related to matters that the service could do better. However, the service was responsive whenever suggestions were made, such as the provision of better information to enable patients to access Wi-Fi access whilst they were on the premises.

Root cause analysis was used to identify learning and ensure action to address shortfalls was appropriate. For example, the service learned from an incident relating to the storage of images taken using the colposcope. The analysis of the incident identified opportunities for error in the way the images were stored. This resulted in a new SOP for the use of the colposcope and a review of the responsibilities during a joint examination.

Effective

No action required

Updated 19 April 2021

Effective needs assessment, care and treatment

Patients’ needs were systematically assessed and their care and treatment was delivered according to standards and evidence based guidance.

Staff carried out thorough assessments of all patients’ needs in accordance with clear clinical pathways that met national FFLM guidance. Health needs identified at initial assessment at the SARC such as the need for PEPSE, for hepatitis B vaccination and for emergency contraception, followed guidance issued by the British Association of Sexual Health and HIV (BASHH) and the Faculty of Sexual and Reproductive Healthcare (FSRH). Patients were referred to the infectious diseases team at Alder Hey if HIV PEPSE was started. This ensured that identified needs were met locally. SOPs provided a consistent approach to sexual health for patients attending the SARC.

All health plans were comprehensive and took account of patients’ physical, emotional and mental health. In records we reviewed, we saw that staff considered whether patients had additional needs and took account of dental health. Staff were alert to the impact and trauma of the alleged sexual abuse and made appropriate referrals to mental health services. Many patients accessing the SARC benefited from the in-house psychology service. The SOP for the paediatric psychology service included pathways to local CAMHS services if needed. This work met guidelines issued by the National Institute for Health and Care Excellence (NICE) and enabled patients to achieve good health outcomes. The psychologist also provided reflective and continuing professional development (CPD) sessions to staff to support their wellbeing and development.

Patients were referred to the local independent sexual violence advocacy (ISVA) service to provide ongoing support to children and young people who had experienced sexual assault. This ensured that children and young people were supported and had ongoing access to advocacy services once they left the centre.

Consent to care and treatment

Staff understood the importance of seeking informed consent. A recent audit of the use of the consent form had provided reassurance that it appropriately explained to patients what would happen during the examination. The audit provided assurance to leaders that staff were using the consent form and the associated SOPs in the correct way.

Patients or carers provided signed consent in accordance with FFLM and GMC guidance at the beginning of their visit. Staff continued to seek consent throughout the examination and to inform the referrals that are made as part of the health action plan. Staff explained that if patients changed their mind at any stage during the examination, they worked with the patient and family to ensure they better understood the procedure, but that patient’s wishes would be respected and the examination would not proceed without consent.

Staff understood legal standards for obtaining consent from children. Staff used the standard for obtaining consent from a young person aged under 16, known as ‘Gillick competence’ and most children and young people attended the SARC with someone with parental responsibility. We saw from our records review that the assessment of Gillick competence was in addition to consent from the person with parental responsibility. The assessment of Gillick competence was well documented by both examining practitioners in the medical reports and the FME notes.

Monitoring care and treatment

There was a multi-disciplinary approach to case management through the weekly case review meetings where every case was discussed. This enabled FMEs and paediatric doctors to reflect on their assessments and for their decisions to be tested. The in-house psychologist attended the case reviews to offer further scrutiny on referrals made for mental health needs. The case review meeting was also used to identify if onward referrals needed follow up. Staff we spoke with told us that they found the case review an important part of their professional development.

A full medical report was prepared for all patients that could be used for a court statement if needed. Medical reports were subject to several quality assurance checks prior to being signed off. All medical reports were signed off by the consultant on call and there was a second layer of quality assurance at the case review meetings. The quality assurance processes ensured the production of holistic, consistent medical reports that accurately identified the needs of the patient.

The service used a peer review process to monitor care and treatment and to ensure that forensic and clinical findings were consistent and reliable. These were delivered jointly with the paediatricians and forensic examiner involved in the case. The Covid-19 pandemic had impacted on the ability of peer reviewers to view images of every examination. which put In particularly challenging cases, staff travelled together to locations to view the images to ensure consistent and reliable findings and outcomes for patients. Staff told us that the issue had been escalated nationally and that they hoped that approval to view images securely and remotely was imminent.

Effective staffing

Patients accessing the Rainbow Centre SARC were assessed and cared for by staff in a range of roles who were competent and had the right skills and knowledge for their role. The SARC followed trust processes to support medical staff in training. This ensured they had the right level of supervision, training and assessment.

Clinical practice was led by a consultant paediatrician who was also a FME and a member of the FFLM. The patient examinations were delivered by a FME and a paediatric doctor or physician associate. The health care assistant supported patients and their families through their SARC experience and ensured they were as comfortable as possible and any stress was minimised. Two of the safeguarding nurses had recently completed the Forensic and Medical Examinations in Rape and Sexual Assault course (FMERSA). They supported with onward referral to meet health needs and delivered the sexual health clinic. On comment cards we saw that patients valued the support offered to them by the healthcare assistant.

Each staff group took part in a comprehensive induction programme at their respective trusts. The induction programme for FMEs was delivered by MUFT. FMEs told us that they valued the local induction and training they were given at Alder Hey and the SOPs that they use to provide consistent care and treatment. The local induction for FMEs was not signed off and this would strengthen the accountability for the local induction of this staff group.

All staff groups were up to date with mandatory training. We saw how managers responded promptly when compliance with mandatory training dropped. Staff developed their skills through regular refresher training in key subjects and topics of interest such as unconscious bias and working with adolescents. The in-house psychologist provided training on adverse childhood experiences. The impact of the training was evident in our review of records.

The culture of regular peer review, case management meetings and regular clinical supervision supported practice improvement. Staff told us they valued these sessions to enable them to reflect and learn from difficult examinations.

Co-ordinating care and treatment

Multi-disciplinary and multi-agency working at the Rainbow Centre SARC was strong, effective and child focused. All health professionals that worked in the SARC had opportunity to support the assessment and planning of patients’ needs through the weekly case review meetings. Every patient that was seen was the subject of at least one strategy meeting. This ensured the right decisions were made at the right time for patients. The SARC leaders had worked with partner agencies through joint audit to improve multi-agency working and increase referrals to the SARC. For example, by increasing the awareness among partners that the on-call Rainbow SARC consultant should be invited to strategy meetings where sexual abuse is suspected. This ensured that the specialist health knowledge was part of the decision as to whether to refer the child for an examination.

The wide-ranging SOPs supported all health professionals to work together and make timely onward referrals. There had been careful planning regarding consultant on call rotas so that there was consistency over a seven-day period. This benefited both patients and staff because there was always support available for staff, and patients’ needs were met during their examination. Out of hours consultants had a handover so that they were sighted on any potential new cases that may be accessing the SARC.

The care pathway into the SARC was clear and was published on the local safeguarding partnerships’ websites. A memorandum of understanding supported the discussion prior to the joint assessment between the FME and the paediatrician. This was provided as guidance to support joint working and staff told us that they were flexible to the patient’s wishes and the skills of the staff. This ensured high-quality, patient focused examinations.

Caring

No action required

Updated 19 April 2021

Kindness, respect and compassion

All staff at the Rainbow Centre children’s SARC understood and respected patients’ needs and showed compassion when providing the service.

Interviews with staff, our review of records and feedback from the patients showed staff were kind, respectful and compassionate to children and young people who had experienced sexual assault. All staff we spoke with were experienced and knowledgeable about the impact and trauma of sexual abuse and were considerate of this when providing care and support. For example, making reasonable adjustments for patients with additional needs and being sensitive to appointment timings when appropriate to fit in with religious activities such as prayers.

Staff allowed patients and their families time to control the examination and they took time to explain processes and next steps. This included giving them a copy of the health action plan that detailed onward referrals and a leaflet setting out what had happened during their time at the SARC.

All the comments cards completed by patients were positive. They noted how the staff were kind and caring and made people feel comfortable in an uncomfortable situation. The service routinely collected feedback from patients through the friends and family test. Our review of the friends and family feedback from July 2020 to December 2020 showed that patients regarded staff as kind, caring and compassionate.

Patients were not routinely advised of the gender of the examining clinicians. There were no male FMEs on the rota but there was some flexibility in the gender of the paediatrician. The SARC should advise patients of the gender of examiners so that patients can make choices. This practice will also contribute to capturing the voice of the child.

Privacy and dignity

Staff at the Rainbow Centre Children’s SARC respected and promoted children and young people’s privacy and dignity.

Patients were able to undress behind a curtain if they wanted to. There were shower facilities with access to toiletries if the patient wanted to use them after the examination. Patients were offered refreshments during their journey through the SARC. All staff told us how they explain the process to patients and their families to ensure they feel fully informed as they progress through the examination.

In our review of the Friends and Family test all patients said they felt treated with dignity and respect. The access to the SARC was discreet and the rooms and corridors were child friendly and clean. The examination room was at the end of the corridor which made the space feel private as it limited the number of people who were walking past. The rooms had been designed by young people through a local consultation exercise.

Due to the Covid-19 pandemic, all leaflets or laminated posters advising people how they could feedback or contact the Patient Advice and Liaison Service (PALS) or make a compliant had been removed. Patients were given leaflets on departure, but this limited the opportunity to provide feedback on the service there and then.

There was an electronic record system in use. Medical staff documented their assessments on paper records during examinations and these were stored securely and were easily retrieved when needed. During our record review we saw examples of body maps completed by the paediatric doctor and FME that gave a comprehensive picture of injuries to the child. The FMEs records were kept at Alder Hey for six months then securely transferred for permanent storage to MUFT premises. We saw through our record review of FME notes that were still present, the examination was documented according to the FME record keeping SOP.

Involving people in decisions about care and treatment

Patients were given enough information to enable them to be involved in decisions about their care and treatment. Families often attended with children and they were also supported through the SARC experience. Staff had access to interpreters when needed to support them in communicating with parents and carers.

The Rainbow SARC does not have its own website, nor does the SARC service appear on the trust directory. This makes it difficult for parents and carers to access information prior to their attendance.

Responsive

No action required

Updated 19 April 2021

Responding to and meeting people’s needs

The Rainbow SARC was well organised to deliver services to meet patients’ needs. We saw through our review of records and our review of the physical environment that the service took account of patients’ needs and was responsive to them. The SARC and all the patient rooms in the SARC were accessible by wheelchair. This ensured that patients with disabilities could access the service at the SARC. The SARC was a child friendly environment with a collection of toys and distraction equipment as needed. This was subject to regular cleaning. It was clear from comments cards that the SARC staff took care of the patient and the adult(s) who were accompanying them.

The Rainbow Children’s SARC is a well-established service with experienced clinical staff and leaders. The service recognised during the early months of the covid-19 pandemic that the numbers of children attending the SARC were significantly lower than they would usually have been. They worked with the Alder Hey youth forum and the NSPCC to publish messages to promote professional vigilance and ensure that people knew the service was still accepting referrals and seeing children and young people. Numbers attending the SARC in subsequent months increased.

The service had established good relationships with multi-agency local partners. This included Merseyside police and Merseyside social care leads. When numbers of children attending the SARC dropped between March and May 2020, in addition to working with the NSPCC, the SARC used established relationships via the Rainbow management meeting to raise concerns. This meant all partners considered actions to raise awareness within their own organisations and there was a multi-agency response to emerging concerns identified by Rainbow SARC staff.

Records that we reviewed showed that patients were referred to the ISVA service. Quality assurance processes for reports ensured that there was appropriate oversight of the initial assessment and provided an opportunity for additional referrals to be considered if needed. We saw that referrals were made to a wide range of services to meet patient’s needs.

Staff at the SARC used local escalation procedures if they did not think safeguarding plans were meeting the needs of children and young people. We saw an example of this when a patient had repeatedly attended the SARC. This means that vulnerable children and young people were kept safe by SARC processes and vigilant staff.

Timely access to services

The service was available 24 hours-a-day seven days-a-week for acute and non-recent cases. The service saw patients for examinations at the best time for the patient and this was rarely ‘out of hours’.

Patients could access the service within an acceptable timescale to meet their needs. During the first six weeks of the pandemic the service stopped seeing non-recent cases although all cases were still triaged. All referrals that were made during that time were subsequently seen in the following months.

All examinations were by appointment and there was an agreed process for securing the input from FMEs. FMEs prioritised children and young people’s SARC examinations due to their age and vulnerability. There was appropriate cover on the FME rota. We saw that in the past when there had been some challenges with covering the FME rota, this was raised with the FME provider and commissioner to ensure that patients continued to access timely care and treatment.

Listening and learning from concerns and complaints

The SARC followed the trust’s complaints policy, however, there had been no complaints to the SARC.

The partnership arrangement between MUFT and Alder Hey Children’s Hospital NHS Foundation Trust identified how complaints about the joint service would be managed. Signs to advise patients about the complaint process had been taken down during the covid-19 period. This means that patients were not provided with a visual reminder about providing their feedback and there was a risk that some patients may not have been enabled to do so.

Well-led

No action required

Updated 19 April 2021

Leadership capacity and capability

Alder Hey Children’s NHS Trust have been the sole provider of the children’s SARC service in this region for many years. The leadership at the SARC has been stable with well established, mature multi-agency relationships that stand up to professional challenge for the best outcome for the patient.

Leaders and all staff at the SARC had a good understanding of their work and about what was important to children and young people. The SARC is part of the Rainbow Centre Safeguarding Hub and so works directly with the Trust’s safeguarding team. This means that there was always additional support in complex cases and experienced staff to provide opportunistic reflective supervision. All staff we spoke with valued the support that they got from leaders and the wider safeguarding service.

Leaders were accessible and visible and knew their staff well. All staff that we spoke with talked positively about the style of leadership from the clinical leads at Alder Hey and MUFT and the operational lead. Staff valued the more formal processes that supported them through the use of SOPs. They valued the support that they got and thought that this helped them to better meet the needs of patients who accessed the SARC.

The operational and clinical leads had clearly defined roles. We saw examples of how they responded to ensure that staff were up to date with mandatory training and how they developed policies and processes following learning events. Leaders told us they were thinking about how the service might evolve to continue to meet the needs of children and young people although there were no formal plans at the time of our inspection.

Vision and strategy

Staff we spoke with were unsure whether the service had a specific vision and values. Managers acknowledged that there was not a formal set of values for the SARC or a shared vision. However, all staff told us that the service was focused on the patient and that staff felt appreciated and knew their role in the SARC. The behaviours and values that staff told us about reflected the trust’s vision to build a brighter future for children and young people. The trust was also supporting Liverpool to become a UNICEF friendly city which put children first and at its heart.

There was a vision for service improvement. This was reported through trust governance processes in the annual safeguarding report and presentation. Key points for the SARC service included ongoing work to improve referral rates. We have seen through our review of evidence that this was promoted by multi-agency audits and effective partnership work. There were ambitions to grow the psychology service following the good outcomes that have been demonstrated so far.

Culture

There was a strong culture of putting patients first and treating patients compassionately. This was evident in our interviews with staff and patients who had provided feedback. Staff felt valued and felt part of a strong team.

There was an open culture for reporting incidents. We saw from our review of incidents that they were reported by all staff disciplines. Learning from incidents was shared at staff meetings. Staff valued the challenge in peer review and the weekly case review management meetings. Staff followed trust processes to ensure they fulfilled their duty of candour when responding to incidents that involved patients. They contributed to an open and honest culture in the SARC.

Governance and management

The assistant director of safeguarding and director of statutory clinical services was the operational lead for the SARC. There was a clinical lead who was a consultant paediatrician and FME. The operational lead reported to the chief nurse. The Named Nurse for Safeguarding supported doctors with child protection investigations and managed the specialist safeguarding nurses that delivered some of the SARC services.

There were clear governance processes that effectively monitored the performance of the SARC. The safeguarding governance meeting provided a framework for leaders to work collaboratively to solve problems and address complex issues. We saw through our review of evidence that there was appropriate prioritisation of issues and accountability for actions. The range of performance metrics including achievements, plans to mitigate risk and challenges, was reported to the Community and Mental Health Divisional Governance Group on a quarterly basis. This group reported to the trust board. This line of governance assured us that staff and leaders understood their service and could account for their actions.

Concerns that we identified during our inspection were acknowledged and responded to swiftly which mitigated risks at the SARC. This response reflected the open culture that staff told us about at the SARC. We were confident that the issues would be addressed and that the leaders and staff managed risk.

Staff we spoke with were clear about their role in the SARC. Including their role to report incidents and discuss concerns. They were aware of the policies and procedures that supported them in their work including information governance.

Staff accessed regular supervision of different forms to support them in their role to deliver safe care and treatment. This included safeguarding supervision, group supervision and ad-hoc supervision from the in-house psychology service. In addition, staff accessed regular peer review and there were weekly supervision drop-in sessions available. The safeguarding team were available to support staff with court processes when needed. The operational lead accessed regular safeguarding supervision with the chief nurse. This ensured that all staff groups felt listened to and were able to reflect on difficult assessments.

Appropriate and accurate information

The Rainbow Centre SARC had a range of data collection methods to assess their performance which they reported on regularly. There were processes in place to ensure that the correct data was collected for every patient. SARC leaders used this data well and had an overarching view of the service. This data was used to populate reports to the trust board and to commissioners and to generate improvement activity where this was required.

Patient information was managed appropriately through clear consent processes at the start of the assessments. When there were concerns about information breaches or storage of records, we saw this was reported and responded to.

Engagement with clients, the public, staff and external partners

The SARC was meaningfully engaged with multi-agency partners. We saw evidence of this through meeting minutes such as the Rainbow management meeting that was attended by multi agency partners. We saw how this was leading to service improvements. Staff regularly attended the North West SARC network events to share practice and hear updates from other SARC providers regionally.

The service gathered feedback from patients through the friends and family test. This feedback was used in reports to the trust and commissioners. There had been limited opportunity to demonstrate improvements in response to client feedback as feedback was overwhelmingly positive.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement, innovation and quality assurance. Action plans to secure improvements were regularly monitored, reviewed and updated.

There was a wide range of training and network days available for all staff to attend. Staff had regular appraisals to ensure their training needs were identified. The staff induction booklet set out expected standards and how to work towards them. Additional funding had been secured to ensure that all staff had access to court process training. The SARC had continued to offer training and networking through the pandemic although some of it had moved to remote provision. Staff told us they valued the training they had access to.

NHSE/I had commissioned a review of SARC provision in the North West. The review was positive for the Rainbow SARC and the recommendations are being monitored through the contract meetings with NHSE/I although there was not an action plan to respond to the recommendations.

The service completed regular audits. This was either as part of the annual audit plan, in response to an incident or in response to a change in data or multi agency concern. We noted that audits were tightly monitored so that the impact of recommendations were reviewed. When areas were re-audited, audit files clearly identified learning at the last audit and what the recommendations were. When we reviewed the FME records we could see the positive impact of the audit and recommendations. This provided assurance that audits are leading to benchmarking and improved practice.

Checks on specific services

Critical care

Good

Updated 21 June 2018

Our rating of this service stayed the same. We rated it as good.

For a summary of this service see overall trust summary section.

End of life care

Good

Updated 8 July 2020

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff to care for children and young people and keep them safe. Staff had training in key skills, understood how to protect children and young people from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to children and young people, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, attended to nutrition and hydration needs appropriately, and gave them anticipatory pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of children and young people, supported them to make decisions about their care, and had access to good information.
  • Staff treated children and young people with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children and young people, families and carers.
  • The service planned care to meet the needs of local people, took account of children and young people’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children and young people and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • At the time of inspection, the substantive palliative care consultant was absent, therefore; there was no set on-call rota in place.

Medical care (including older people’s care)

Good

Updated 5 October 2017

  • There was a positive culture of incident reporting at ward level and there was evidence of learning and changes in practice following incidents. Staff felt supported by their immediate team colleagues and by senior managers.

  • Staffing levels and skill mix was planned, implemented, and reviewed to keep children and young people safe.

  • Consultants took part in a ‘Consultant of the week’ rota and were present in the hospital during times of peak activity.

  • Age dependent pain assessment tools were in use and analgesia was available to children who required it.

  • The environment was suitable and welcoming to meet the needs of children and young people and their parents and carers. Services were planned and delivered to meet the needs of local area, the North West of England, North Wales and the Isle of Man.

  • We found consent to treatment was clearly recorded in the records we reviewed. We observed staff interacting with patients and their relatives with kindness, dignity and respect. Parents and patients told us they were included in decisions about their care and were kept well informed. The patients and parents we spoke with were extremely positive about the care they received and one parent told us “the staff are like a family, we will miss them when the treatment finishes”.

  • The trust had achieved 100% compliance with all cancer waiting times for the period April 2016 to March 2017 except for one month where they achieved 88%.

  • There was a clear vision which was aligned with the trust vision to provide ‘a healthier future for children and young people’ which was underpinned by a set of values. We observed staff demonstrate the set of values when they were delivering care.

  • There was a process in place to enable the performance, safety, and quality of the service to be reported and reviewed. Risk registers were held at ward and clinical business unit level with a process to escalate risks to keep children and young people free from harm.

Neonatal services

Good

Updated 8 July 2020

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse. The service controlled infection risk well. Staff assessed risks to patients and acted on them and kept care records securely. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients sufficient nutrition, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised their parents how to support them to lead healthier lives, supported families to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped their parents to understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for patients’ families to give feedback. Children could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.


However:

  • The design of the premises did not maintain the security of children and their families at all times. The service had not minimalised potential security risks to babies due to the design or the premises and security systems used.
  • The numbers of nurses with a recognised neonatal qualification was not in line with recognised standards.
  • There were omissions in medical records.

Surgery

Good

Updated 8 July 2020

Our rating of this service improved. We rated it as good because:

  • The service had enough nursing, medical, theatre and support staff to keep children and young people safe and mandatory training levels were mostly achieved. Safeguarding processes were in place and staff knew how to recognise and report abuse. The service controlled infection risk well and kept the premises visibly clean. The design, maintenance and use of facilities, premises and equipment kept people safe. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed children and young people safety incidents well.
  • Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated children and young people with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children and young people, families and carers.
  • The service planned care to meet the needs of local people, took account of children and young people individual needs. The service made it easy for people to give feedback and investigated and learned from complaints. Waiting times from referral to treatment and arrangements to admit, treat and discharge children and young people were in line with national standards.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. The service had a vision for what it wanted to achieve and a strategy to turn it into action. Staff felt respected, supported and valued. They were focused on the needs of children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with staff and the patient community to plan and manage services and all staff were committed to improving services continually.


However:

  • Agency staff induction was not always evidenced. Theatre staff did not always follow safety standards when conducting the count out. The checklist used in theatres was not compliant with ‘National Safety Standards for Invasive Procedures’ (NatSSIPs). Fridge temperatures were not always recorded or escalated appropriately. Some patient group directions (PGD) were past their review date. Staff did not have oversight of ward attenders on ward 4a.
  • Staff did not always follow consent best practice following a capacity assessment. The service did not currently audit consent processes.
  • Children were required to wait in the waiting room before their surgery in pyjamas or surgical gowns. This may not always respect their privacy or dignity.
  • The service did not have enough play specialists to meet the need of all children and young people. The percentage of cancelled elective operations for non-clinical reasons at the trust was higher than the England average. The department was not meeting the trust target of 25 working days to investigate and close complaints.
  • Staff felt there was not always opportunities provided for career development. Staff in day case area did not feel supported due to a recent organisational change.

Transitional services

Good

Updated 23 December 2015

At our previous visit in May 2014 we found that transitional services required improvement. In June 2015, we returned to inspect the whole service. We saw that there had been significant improvements since our last inspection. We found that the trust had a co-ordinated trust wide strategy for planning and delivering transition services which supported young people. There were excellent examples of transition pathways for young people with specific long-term needs. There was a commitment from the trust to further develop existing partnerships with health and social care providers of adult services. Since our last inspection, the trust had appointed a designated transition nurse and named medical consultant. As a result, progress had been made in developing over-arching policies and procedures relating to transition arrangements for young people with complex needs. These were due to be formally rolled out across the trust shortly after our inspection. There was clear leadership, vision and a desire to use research and audit programmes to share good practice and identify gaps in transition and use this to improve outcomes for young people. There was evidence of patient, public and staff involvement in shaping policies and procedures related to transition.

Urgent and emergency services

Good

Updated 8 July 2020

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff to care for children and young people and keep them safe. Staff had training in key skills, understood how to protect children and young people from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to children and young people, acted on them and kept good clinical care records. They managed most medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave children and young people enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated children and young people with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children and young people, families and carers.
  • The service planned care to meet the needs of local people, took account of children and young people’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
  • Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values. Staff felt respected, supported and valued. They were focused on the needs of children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children and young people and the community to plan and manage services and all staff were committed to improving services continually.


However:

  • The service did not have robust governance arrangements for risk assessments, stock control and toy cleaning schedules.
  • Mandatory training compliance was below the trust target in some modules. In relation to nurse staffing, in five out of 11 modules the 90% target was not achieved. For medical staffing, the trust’s target was not achieved in seven out of eight modules.
  • Waiting times from referral to treatment and arrangements to admit, treat and discharge children and young people were not always in line with national standards.

Outpatients

Good

Updated 8 July 2020

Our rating of this service improved. We rated it as good because:

The trust’s outpatient’s department consists of services based within a new hospital building. The department includes clinical specialities including physiotherapy; phlebotomy; dental; occupational therapy; ear, nose and throat; fracture; cardiology; respiratory; cystic fibrosis; and ophthalmology. It also includes a general paediatric clinic.

The department has administrative functions such as medical records, transcription services, and booking and scheduling. These services are based within the old estate next to the new hospital.

We plan our inspections based on everything we know about services including whether they appear to be getting better or worse.

We inspected the outpatient department between 21 and 23 January 2020. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. As part of the inspection we reviewed information provided by the trust about staffing, training and monitoring of performance.

During the inspection the inspection team visited three floors of the outpatient department within the new building, and some of the administrative functions within the old estate. The inspection team spoke with 14 children and young people and carers who were using the service, and 32 staff members including managers, consultants, reception staff, play specialist, nurses, healthcare assistants and administrative staff. We reviewed 16 patient records.

Diagnostic imaging

Good

Updated 21 June 2018

We have not inspected this service before. We rated it as good.

For al summary of this service see the overall trust summary section.

Other CQC inspections of services

Community & mental health inspection reports for Alder Hey Children's Hospital can be found at Alder Hey Children's NHS Foundation Trust.