The Care Quality Commission
  • Doctor
  • Independent doctor

Beech House

Unit 7-8, North Court, Armstrong Road, Maidstone, Kent, ME15 6JZ (01622) 726461

Provided and run by:
Mountain Healthcare Limited

Important: This service was previously registered at a different address - see old profile

All Inspections

26 April 2023

During an inspection looking at part of the service

Summary findings

We carried out this targeted announced inspection on 26th April 2023 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions to follow up on concerns that had been identified in a previous inspection which was undertaken on 2nd and 3rd August 2022. 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 and an additional CQC inspector.

We focused on specific parts of the service’s governance. These are:

  • To ensure an effective mechanism to identify and remove out of date consumables, for example swabs and bandages
  • To ensure all clinical records are legible and that corrections meet record keeping standards
  • To ensure effective mechanisms are in place to monitor and mitigate risk
  • To ensure staff receive outcomes and learning from incidents they have reported

This targeted inspection only looked at this key question;

• Is it well-led?

We found that the provider was compliant with Regulation 17 (1), 17 (2) (b) and 17 (2) (c) 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

Beech House SARC (Sexual Assault Referral Centre) is situated in Maidstone and provides services to adults and children who have experienced sexual abuse or sexual violence either recently, or in the past. The service is provided by Mountain Healthcare Limited (MHL) and delivered from secure rented premises in a quiet commercial estate. There is parking to the front of the building. The service is on the ground floor.

The SARC includes two forensic suites, (one for adults and one for children) each contains an adjoining forensic waiting area, medical examination room, shower room and a non-forensic aftercare room.

For the purpose of this targeted inspection we focused on provision for 0-18- year olds. The adult service was inspected by the CQC in 2018. The service is provided by MHL and is commissioned by NHSE (National Health Service England) and the Kent Police and Crime Commissioner.

The service offer is 9am - 5pm Monday to Friday excluding Bank Holidays. If children need be seen outside of this time frame to meet the forensic window alternative arrangements are made.

On the day of the inspection, we spoke with regional managers for Mountain Healthcare Limited and a crisis worker.

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

Our key findings were:

  • Improvements had been made since our last inspection of 2nd and 3rd August 2022.
  • All consumables seen in the storage area were in date. Leaders had created a Standard Operating Procedure (SOP) regarding the management of equipment and consumable items. We did see a discrepancy for the number of items currently held in the storage area. This was addressed immediately by correcting the issue and a reminder to sent to all staff to follow the SOP.
  • Clinical records reviewed were legible and adhered to record keeping standards
  • Clear mechanisms were in place to manage and mitigate risk. We saw a number of examples of how risk is identified, managed, logged and then reviewed by leaders and staff. Leaders have also increased the frequency of meetings with the SARC manager to review identified risks and mitigations.
  • We saw how staff receive learning and outcomes from incidents reported in a number of ways. Through individual meetings, within team meetings and by information made available on the service intranet.

02.08.2022 to 03.08.2022

During a routine inspection

Summary findings

We carried out this announced inspection on 2nd and 3rd August 2022 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 and a specialist professional advisor.

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.

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 not providing well led care in accordance with the relevant regulations. Once the shortcomings have been put right the likelihood of them occurring in the future is low. We have told the provider to take action (see full details of this action in the Requirement Notices at the end of this report). We will be following up on our concerns to ensure they have been put right by the provider.

Background

Beech House SARC (Sexual Assault Referral Centre) is situated in Maidstone and provides services to adults and children who have experienced sexual abuse or sexual violence either recently, or in the past. The service is provided by Mountain Healthcare Limited (MHL) and delivered from secure rented premises in a quiet commercial estate. There is parking to the front of the building. The service is on the ground floor.

The SARC includes two forensic suites, (one for adults and one for children) each contains an adjoining forensic waiting area, medical examination room, shower room and a non-forensic aftercare room.

For the purpose of this inspection we focused on provision for 0-18- year olds. The adult service was inspected by the CQC in 2018. The service is provided by MHL and is commissioned by NHSE (National Health Service England) and the Kent Police and Crime Commissioner. Throughout this report we have used the term ‘children’ to describe people who use the service to reflect our inspection of the clinical aspects of the SARC.

The paediatric team for children 0-13 years consists of one Forensic Medical Examiner (FME) and one whole time equivalent crisis worker. They are supported by the SARC manager, forensic nurses and crisis workers. The FME is a member of the Faculty for Forensic and Legal Medicine (FFLM) and provided a holistic assessment for the children she cared for.

Children over the age of 13 were generally seen by Forensic Nurse Examiners (FNEs) and adult crisis workers, however in exceptional circumstances the FME or a community paediatrician would support the FNE, for example if a child has a learning disability.

The under 13 service offer is 9am - 5pm Monday to Friday excluding Bank Holidays. If children need be seen outside of this time frame to meet the forensic window alternative arrangements are made.

During the inspection we interviewed eight staff members: the registered manager, the regional director, the FME, two FNEs, a paediatric crisis worker, an adult crisis worker and male outreach worker.

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

We reviewed nine care records for children aged 0-18 years old who had accessed the SARC within the last 6 months.

Our key findings were:

  • The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • Clinical staff provided care and treatment in line with current guidelines.
  • All staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The appointment/referral system was adaptable and met children's needs.
  • The provider encouraged staff and patient feedback about the services they provided.
  • The provider had suitable information governance arrangements.
  • Infection control procedures reflected published guidance.

We identified areas where the provider could make improvements.

They must:

  • Ensure there is an effective mechanism to identify and remove out of date consumables, for example swabs and bandages.
  • Ensure all records are legible and corrections meet record keeping standards.
  • Ensure effective mechanisms are in place to monitor and mitigate risk.
  • Ensure staff receive outcomes and learning from incidents they have reported.

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

They should:

  • Provide written information for children and families who do not speak English.

No visit - desk based review

During a routine inspection

We carried out a focused desk based review of healthcare services provided by Mountain Healthcare Limited (MHL) at Beech House in March 2020.

The purpose of this review was to determine if the healthcare services provided by MHL 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 services provided in sexual assault referral centres.

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

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services responsive?

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

In Kent, services for the support and examination of people who have experienced sexual assault are commissioned by NHS England. The contract for the provision of sexual assault referral centre services in Kent (for patients over the age of 14) is held by Mountain Healthcare Limited (MHL). MHL is registered with CQC to provide the regulated activities of diagnostic and screening procedures, and treatment of disease, disorder or injury.

Beech House is located in Maidstone, Kent in secure rented premises.

We last inspected the service in February 2019 when we judged that MHL was in breach of CQC regulations. We issued a Requirement Notice on 24 June 2019 in relation to Regulation 17, Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

https://www.cqc.org.uk/location/1-3197587861

This desk based review was conducted by one CQC health and justice inspector and included a review of evidence and a teleconference with the centre manager and director of nursing.

Before this review we reviewed the action plan submitted by MHL to demonstrate how they would achieve compliance, and a range of documents submitted by MHL. We also reviewed information provided by NHS England commissioners.

Documents we reviewed included:

  • Current training and supervision matrices
  • Risk register
  • Premises risk register
  • Revised patient record templates
  • Patient information literature
  • Quarterly quality reports for 2019
  • Audit schedules for 2019 and 2020

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

At this inspection we found:

  • The provider had effective oversight of the risk register and managers reviewed this regularly.
  • The provider and managers were proactively developing local and national SARC services in response to the outcome of CQC inspections.
  • Staff training and supervision were now routinely monitored by the centre manager and MHL senior managers.
  • The provider had worked with the police to ensure that window restrictors were fitted to first floor windows.
  • The provider had amended record templates and introduced easy to read consent information for patients. Patient records clearly documented how the patient’s capacity to consent was ascertained.
  • A variety of easy to read and child/young person friendly literature was available.
  • Managers had amended patient feedback forms and introduced an easy read child friendly form to increase patient feedback about the service.
  • The provider had made a range of improvements around safeguarding arrangements.

12 & 13 February 2019

During a routine inspection

We carried out this announced inspection on 12 and 13 February 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, and a specialist professional advisor.

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

Beech House SARC is in Maidstone and provides services to adults and children who have experienced sexual abuse or sexual violence either recently, or in the past. NHS England commission community paediatricians to deliver the medical examinations for under 13 year olds, who are overseen by a Mountain Healthcare Forensic Medical Examiner.

The service is delivered from secure rented premises and offers access for patients with disabilities. The accommodation includes three forensic suites, each contains an adjoining forensic waiting area, medical examination room, shower room and aftercare room.

The team includes a service manager, one doctor, eight forensic nurse examiners, and eight crisis workers.

The service is provided by Mountain Healthcare Limited 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.

During the inspection we spoke with four staff members, and looked at policies, procedures and other records about how the service was managed. We reviewed care records for 8 patients who had accessed the SARC within the last 6 months.

The service is accessible 24 hours a day, seven days a week.

Our key findings were:

  • The provider did not have adequate local systems and processes in place to identify where quality and safety were compromised.
  • The SARC did not have effective leadership and there was no culture of continuous improvement.
  • The premises were clean and well maintained.
  • The staff used infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The staff followed suitable safeguarding processes and knew their responsibilities for safeguarding adults and children. However not all staff had not received up to date safeguarding training.
  • The provider had thorough staff recruitment procedures.
  • 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 provider asked patients for feedback about the services they provided but this was limited and therefore learning from patient feedback was under developed.
  • The staff had suitable information governance arrangements.

We identified one regulation the provider was not meeting. The provider must:

  • Ensure that there are local systems and processes to identify where quality and safety are compromised.
  • Provide regular supervision for all staff in accordance with the provider’s policy.
  • Monitor and ensure all staff are up to date with their mandatory training.

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

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

  • Risk assess first floor windows where no window restrictors were in place.
  • Ensure that care records thoroughly detail the rationale for determining whether a patient does or does not have capacity to consent to treatment.
  • Provide child-friendly literature for children to take away following their treatment at the SARC.
  • Embed new patient feedback mechanisms to obtain detailed feedback from patients to help improve the service.