King's College Hospital

Whilst we recognised work had been undertaken by the service to correct the concerns raised during the previous inspection, we found that further work was required to demonstrate clear sustainable results.

Mandatory training rates were still variable across the staff groups and during the rolling year of the training schedule. Completion rates provided showed some subjects with completions rates as low as 22% for one subject.

The rotating and stock control of single use consumables still required work as we found a significant number of items which were past their use by date. ED safety checklist completion rates were not in line with trust target and completion was at times sporadic.

The cubicle which was used as a mental health safe assessment room in the paediatric ED still was not fit for purpose. Although we recognised the work the service had done to mitigate risks and the planned building work which was due to commence shortly after the inspection. Despite this, at the time of the inspection the risks remained.

Access and flow within the department remain a concern but we recognise the work undertaken by the service to alleviate this situation where possible.

However:

We saw improvement in the safety checking of resuscitation trolleys, the storage of medicines in fridges which had been fitted with digital locks, correct administration and safe dosage of medicines given to patients. We found there was now a private area within reception for patients to use and plans had been agreed to build a mental health safe room for children in the paediatric ED.

There were new protocols for the use of resus room 10 for administration of intramuscular sedation. This provided assurance of the safe and appropriate use of this room when treating children with mental ill health.

We carried out this announced inspection of The Havens sexual assault referral service over two days on 21 and 22 May 2019. We conducted this inspection 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 of the Health and Social Care Act 2008 and associated regulations. Two CQC inspectors, supported by a specialist professional adviser, carried out this inspection.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions about a service:

• 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 Havens sexual assault referral service is provided by Kings College NHS Foundation Trust at three sexual assault referral centres (SARC) in London; one site close to Kings College Hospital in Camberwell, one site close to St Mary’s Hospital in Paddington and one site close to the Royal London Hospital in Whitechapel.

Each of the centres has a dedicated entrance with separate pathways for patients who use the forensic service and for those using only the follow-up services. All three centres follow the same common processes and procedures and, although there are local managers in place, each centre is subject of the same central governance and oversight.

Each of the buildings occupied by the centres is configured differently, although each centre has dedicated forensic examination rooms and associated waiting rooms for children and for adults.

NHS England (NHSE) and the Mayor’s Office for Policing and Crime (MOPAC) jointly commission The Havens, which is the only sexual assault referral service in London. The service provides forensic medical examinations and related health services to people living in all of the London Boroughs (the Metropolitan Police area) who have been sexually assaulted. This includes the offer of an independent sexual violence adviser (ISVA) to co-ordinate follow-up care and support for patients. The service also provides a range of additional follow-up psychology services for children and adults although these were not in the scope of our inspection

The Havens is an ‘all-age’ service; that is, adults aged 18 and over, children aged13 and above and children under the age of 13. The service is accessible to male, female and transgender patients.

The service is available 24 hours each day with patients directed to the most appropriate centre where they can be seen quickly. Patients are referred through the police (or child protection processes for patients under 13). Patients aged between 13 and 17 may be brought to the centres by police or a social worker but can also self-refer subject to safeguards in relation to their capacity to consent. Patients aged 18 and over can self-refer without police involvement.

The Havens has an integrated central management structure comprising a service manager and medical and nursing leads. Each centre has a service delivery manager together with doctors who are sexual offence examiners (SOE), forensic nurse examiners (FNE), and nursing staff and duty crisis workers who carry out the role of crisis worker.”. There are specialist paediatric and psychology staff, as well as ISVA workers for both adults and children, nurses who provide crisis support, forensic nurse examiners (FNE) and business support staff who perform a variety of roles. Most staff members work from their base site, although clinical staff may be called to any of the three sites. There are also some medical, paediatric and crisis worker staff who carry out sexual offence examinations on an on-call, sessional basis at any of the sites.

As the service is provided by KCHFT, the trust is responsible for meeting the requirements on the Health and Social Care Act 2008, and the associated regulations about how the service is run.

During our inspection we spoke with the service manager, the service delivery managers for each of the sites, both consultant co-clinical leads, a lead doctor from each of the three Havens sites and a specialty doctor. We also spoke with the interim lead nurse and senior forensic nurse examiner, a senior nursing sister (who is also a crisis worker), a senior crisis worker, an adult ISVA, a young person’s ISVA, the family nurse advocate and the child clinical support worker. We looked at records of eight patients. Two of these were children under 13, two were young adults over 18 and four were older adults. Six were female patients and two were male.

We left comment cards at the location in the two weeks prior to our visit and received 29 responses from people who had used the service in that period. We also spoke directly with three people who had used the service recently.

We looked at the policies and procedures that were used commonly across all three sites and examined performance and quality monitoring information and training data.

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:

• Staff knew how to deal with emergencies.
• Appropriate medicines and life-saving equipment were available.
• The service had systems to help them manage risk.
• The staff had effective safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• The service was clean and well maintained.
• The staff had infection control procedures which reflected published guidance.
• The service had thorough, safe, staff recruitment procedures.
• The clinical staff provided patients’ care and treatment in line with current guidelines issued by the relevant professional bodies.
• There were processes for monitoring the standard and quality of care.
• Staff treated patients with dignity, respect and compassion and took care to protect their privacy and personal information.
• The single point of access referral system met patients’ needs.
• 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 and acted on this.
• The service dealt efficiently with adverse incidents, complaints and feedback.

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

• Complete first stage risk assessments fully for each patient.
• Account accurately for medicine stocks used.
• Provide written information about the service and its procedures, and in a suitable format, for younger children, patients with a learning disability and patients whose first language is not English.
• Provide information to all patients about the gender of the clinician.

Our rating of services stayed the same. We rated it them as requires improvement because:

• Not all staff had completed the required safety related mandatory training, which was as we found on our previous inspection.
• The environment in which patients received treatment and care was not always suitable or risk assessed. Privacy was not always achieved in some areas, and equipment had not been checked in a consistent manner.
• Medicines optimisation was not always achieved, and standards related to infection prevention and control were inconsistent.
• Patient risk assessments were not always completed and updated.
• Expected patient outcomes were not always met in some specialties.
• Access to some services were not meeting some of the expected targets in outpatients and once referred for admission. Waiting times from referral to treatment, arrangements to admit, treat and discharge patients was not always in line with good practice.
• Communication and engagement with staff by leaders was not always as strong as it could be, and some staff reported low morale.

However:

• There were enough staff with the right skills and experiences and staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance.
• Care and treatment was delivered by a multidisciplinary team, in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) and professional colleges.
• The staff recognised the importance of reporting and learning from incidents. Investigations led to the sharing of information learned and improvements.
• Patients were treated with respect and dignity, were involved in decisions about their care and were provided with information and choices.
• The co-ordination and delivery of services took account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.
• Most clinical areas were led by staff who had the right experience, skills and knowledge. They understood the trusts values and strategic aims and fostered a culture where staff could do their best.

Our rating of services stayed the same. We rated it them as requires improvement because:

• Not all staff had completed the required safety related mandatory training, which was as we found on our previous inspection.

• The environment in which patients received treatment and care was not always suitable or risk assessed. Privacy was not always achieved in some areas, and equipment had not been checked in a consistent manner.

• Medicines optimisation was not always achieved, and standards related to infection prevention and control were inconsistent.

• Patient risk assessments were not always completed and updated.

• Expected patient outcomes were not always met in some specialties.

• Access to some services were not meeting some of the expected targets in outpatients and once referred for admission. Waiting times from referral to treatment, arrangements to admit, treat and discharge patients was not always in line with good practice.

• Communication and engagement with staff by leaders was not always as strong as it could be, and some staff reported low morale.

However:

• There were enough staff with the right skills and experiences and staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance.

• Care and treatment was delivered by a multidisciplinary team, in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) and professional colleges.

• The staff recognised the importance of reporting and learning from incidents. Investigations led to the sharing of information learned and improvements.

• Patients were treated with respect and dignity, were involved in decisions about their care and were provided with information and choices.

• The co-ordination and delivery of services took account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

• Most clinical areas were led by staff who had the right experience, skills and knowledge. They understood the trusts values and strategic aims and fostered a culture where staff could do their best.