The Care Quality Commission
  • Community
  • Community healthcare service

Topaz Centre

Oxclose Lane, Arnold, Nottingham, NG5 6FZ 0800 085 9993

Provided and run by:
Mountain Healthcare Limited

All Inspections

7 March 2024

During a routine inspection

We carried out this announced inspection on 7 March 2024 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 undertaken by 2 CQC inspectors.

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

Topaz Centre Sexual Assault Referral Centre (SARC) is located in Nottingham and provides services to adults aged 18 and over. Children aged 16 or 17 may be seen at the centre if appropriate. The service is available 24 hours a day, 7 days a week and provides forensic medical examinations, advice to police and patients, support following sexual abuse, and onward referrals to independent sexual violence advisors (ISVA).

The SARC is commissioned by NHS England and provided by Mountain Healthcare Limited. As a condition of registration, the provider 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. At the time of our inspection, the service had a registered manager in post who oversaw the service as well as a newly appointed manager who was applying for CQC registration.

The SARC is based in new purpose-built accommodation owned by Nottinghamshire Police. The accommodation is secure and discrete and has a range of facilities including two forensic suites with adjoining waiting areas and shower rooms, video assisted interview rooms, a laundry room, family rooms and secure gardens.

At the time of our inspection, the local team was made up of a service manager, two full-time forensic nurse examiners and three part-time administrator/crisis workers (1 whole time equivalent). The team was supported by an associate head of healthcare and a regional contract director.

The registered manager is a member of the Faculty of Forensic and Legal Medicine (FFLM).

Before the inspection, we spoke to the commissioner of the service and looked at a range of policies, procedures and other records to learn about the service. During the inspection, we undertook a tour of the environment, spoke with 5 staff members, and reviewed care records for 6 patients who had attended the SARC in the previous 12 months.

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

Our key findings were:

  • The environment appeared clean and well maintained.
  • The service had robust systems to help them manage risks presented to the service.
  • The provider had clear safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • Staff knew how to deal with medical emergencies. Appropriate medicines and life-saving equipment were available.
  • Clinical staff provided patients’ care and treatment in line with current guidelines.
  • The service had thorough staff recruitment procedures.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The referral and appointment system met patients’ needs.
  • Staff dealt with complaints efficiently.
  • Staff felt involved and supported and worked well as a team.
  • The service asked staff and patients for feedback about the services they provided.
  • The service had good information governance arrangements.

The service had effective leadership and a culture of continuous improvement.

No visit desk top inspection

During a routine inspection

We do not currently rate services provided in sexual assault referral centres.

Background

In Nottingham, 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 for adults in Nottingham 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.

The Topaz Centre is located in Nottingham in secure rented premises.

We last inspected the service in March 2019 when we judged that MHL was in breach of CQC regulations. We issued a Requirement Notice on 8 August 2019 in relation to Regulation 17, Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

https://www.cqc.org.uk/location/1-5056179055

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.

Documents we reviewed included:

  • Current training and supervision matrices
  • Temperature logs for rooms where medicines were stored
  • New safeguarding arrangements
  • Centre attendance data for the last 12 months

We did not visit the Topaz Centre 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:

  • Staff records demonstrated staff were appropriately trained to provide effective patient care
  • Patients could be offered direct referrals into psychological therapy or sexual violence counselling support services.
  • Staff training and supervision were routinely monitored by the centre manager and MHL senior managers
  • The provider had worked with the police to help ensure infection prevention and control risks were addressed in the premises
  • The provider had made several changes to improve safeguarding arrangements for patients
  • The Topaz Centre staff worked actively with local partners to improve access and support for people who had experienced sexual violence
  • The governance around medicines management had improved, and staff followed appropriate guidance.

26 and 27 March 2019

During a routine inspection

We carried out this announced inspection on 26 and 27 March 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

The Topaz Centre SARC is in Nottingham and provides services to adults aged 18 and over. Children aged 16 or 17 may be seen at the centre upon request.

The service is delivered from secure rented premises and offers access for patients with disabilities. The accommodation includes two forensic suites, one with a separate waiting area and shower room, and one with an adjoining waiting area and shower room.

The team includes a service manager, seven forensic nurse examiners (three of whom have zero hour contracts), and eleven crisis/admin workers.

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 responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations regarding how the service is run.

During the inspection we spoke with six staff members, and looked at policies, procedures and other records about how the service was managed. We reviewed care records for 12 patients who had accessed the SARC within the last 12 months.

The service is accessible 24 hours a day, 7 days a week.

Our key findings were:

  • The provider did not have effective systems in place to help them monitor staff training, and supervision was not documented.
  • The staff used infection control procedures which reflected published guidance, however the premises were not fit for purpose and new premises were being discussed with commissioners.
  • 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.
  • The provider had thorough staff recruitment procedures.
  • The clinical staff provided patients’ assessment, care and treatment in line with the Faculty for Forensic and Legal Medicine (FFLM) 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 offerred and made changes as a result of feedback.
  • The staff had suitable information governance arrangements.

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

  • Document 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:

  • Ensure all risks known to managers are documented on the local risk register.
  • Embed daily monitoring and recording of room and fridge temperatures where medicines are stored.
  • Review patient group directions ensuring these are individually signed by all clinical staff.