We carried out this announced inspection over two days, 20 and 21 November 2018, 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 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 Solace Centre is based in Cobham and offers a range of support services to anyone aged 13 or over, living within the Surrey area who have experienced sexual abuse or sexual violence, either recently or in the past. The service is available 24/7 to help people that have been affected by sexual abuse and sexual violence. For those children aged 13 and under, the Solace Centre supports community paediatricians from Monday to Friday (9am – 5pm), offering paediatric examinations and support.

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 about how the service is run. The registered manager was the SARC manager.

The service is located on the first floor 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 inspection, we spoke with the registered manager, the nominated individual who is also the medical director, the director of integration and collaboration, a counsellor, two forensic nurse examiners, a medical practitioner with the local clinical lead and also with administration staff. We also looked at policies and procedures and other records about how the service is managed.

The paediatric services at this service are undertaken by a different provider which were not reviewed as part of this inspection.

Our key findings were:

• Staff knew how to deal with emergencies.
• Appropriate medicines and life-saving equipment were available.
• The service had systems to help them manage risk, however, they had not considered risks such as lone working.
• The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The service had thorough staff recruitment procedures.
• The clinical staff provided clients’ care and treatment in line with current guidelines.
• Staff treated clients with dignity and respect and took care to protect their privacy and personal information.
• 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 staff and clients for feedback about the services they provided.
• The service staff dealt with complaints positively and efficiently.
• The staff had suitable information governance arrangements.

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

• Review and update all the policies, procedures and risk assessments to ensure they are current, in date and meet local requirements.
• The service should develop a localised business continuity plan.
• The service should ensure that safeguarding training is increased from 75% of staff to 100%.