Updated 8 December 2021
We carried out a focused inspection of healthcare services provided by Mountain Healthcare Limited at The Horizon SARC (Sexual Assault Referral Centre) on 2nd November 2021.
The purpose of this inspection was to determine whether Mountain Healthcare Limited were meeting the legal requirements and regulations under Section 60 of the Health and Social Care Act 2008.
During this inspection we focused on compliance with the warning notices issued on 19 August 2021 relating to:
Are services safe?
Are services well-led?
We found that the provider was compliant with Regulation 13(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 17 (1), of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We do not currently rate the services provided in sexual assault referral centres.
Background:
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 and young people aged 18-25 years with complex needs who have experienced sexual assault or abuse. This service is registered with CQC as The Horizon SARC to provide the regulated activities of diagnostic and screening procedures, and treatment of disease, disorder or injury.
As Mountain Healthcare 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 Clinical Services Director who is also part of the MHL senior leadership team. However, a SARC manager, who is part of the Forensic Nurse Examiner (FNE) team, conducts the day-to-day management of the SARC.
We last inspected the service in August 2021 and found that Mountain Healthcare were in breach of CQC regulations. We issued warning notices on 19 August 2021 in relation to Regulation 13(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 17 (1), of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
This focused inspection was conducted by two CQC Children’s Services Inspectors.
During this focused inspection we reviewed seven case records and documents submitted by Mountain Healthcare Limited to demonstrate how they have achieved compliance.
At this inspection we found:
- The provider was compliant with Regulation 13(1) and Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
- Following our previous inspection, gaps in information sharing were recognised by the provider and the issue was noted in the location’s risk register. There were clear actions to mitigate this risk.
- The provider had effective systems to monitor the quality of the service and mitigate risks to children using the SARC.
- In three of the cases, information had not been shared with children’s social care in the original safeguarding alert and the Multi Agency Referral Form (MARF). The providers’ operational governance process identified these gaps and ensured missing information was shared with children’s social care.
- A supervision and appraisal tracker were being well utilised to demonstrate operational and safeguarding supervision had taken place for Forensic Nurse Examiners (FNEs) and Forensic Medical Examiners (FMEs).
- Child voices were more evident in case records, however there are still opportunities for improvement.