Updated 3 January 2024
We carried out this focused announced inspection on 2 October 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 29 November 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. The inspection was a desk-based review and did not include a site visit. We focused on a specific part of the service that is offered to patients under 13 years of age, and who had been affected by recent sexual abuse and sexual assault (‘recent’ means less than 72 hours from when the incident took place). Services provided to children under 13, and who had been affected by non-recent sexual abuse and sexual assault are undertaken by a different provider and were not inspected as part of this inspection (‘non-recent’ means more than 72 hours since the incident took place). To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions; is the service safe, effective, caring, responsive and well-led? This targeted inspection only looked at parts of the following key question: Is it well-led? This question forms the framework for the areas we look at during the inspection.
Background
The Solace Centre is based in Cobham and offers a range of support services to anyone across all ages, living within the Surrey area who have experienced sexual abuse or sexual assault, either recently or in the past. For those patients aged 13 and under, forensic medical examiners employed by Mountain Healthcare led on recent cases. They were supported by paediatricians from a local NHS trust, however, no joint working arrangements for this had been formalised at the time of our visit in November 2022. This service is available between Monday and Friday (9am-5pm). Referrals are made to an alternative provider outside of these hours when needed. The service is provided by Mountain Healthcare Limited and as a condition of registration they must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibilities for meeting the requirements of the Health and Social Care Act 2008 and associated regulations about how the service is run. At the time of our inspection the registered manager was the SARC regional contracts manager. The service is located on the first floor of Cobham Community Hospital and has full access for people who use wheelchairs and those with pushchairs. Car parking spaces are available at the hospital including a number of spaces for blue badge holders. On the day of the inspection, we looked at policies and procedures and other records about how the service is managed. We reviewed all information through a desk-based review. This inspection did not include a site visit.
Our key findings were:
• The service had systems to help them manage risk.
• The service had systems and processes which informed their governance arrangements.
There was one area where the provider should make improvements. They should:
• Develop a standardised procedure to ensure oversight of the disclosure and barring service status for any paediatrician employed by the local NHS trust working in the SARC. This should include a policy which outlines the frequency of checks to be undertaken.