During an assessment of Diagnostic and screening services
The date of the assessment 4 March 2026
This was the first assessment for this service since registering with the CQC in July 2021.
We rated the service as good. Staff assessed and mitigated risks. Care plans were guided by safe practice. The provider had enough staff to ensure people’s safety and meet their needs.
- The service provided safe care and treatment, staff completed holistic and timely risk assessments, and care was well planned. Staff understood how to safeguard people from abuse and neglect. Staff worked well together for the benefit of pregnant women and supported them to make informed decisions about their care. The service had considered the impact that a potential failed pregnancy may have and provided support for pregnant women. They ensured that referrals to stakeholders were made in a timely manner. Staff maintained accurate records.
- The service planned care to meet the needs of the local population and made it easy for people to provide feedback which was very positive.
- The service was accessible and supported local NHS wait times and staff engaged well with women and stakeholders. Staff had formed meaningful relationships with families who used the service for more than one pregnancy because they felt cared for and respected.
- The registered manager was approachable, and staff felt respected and included in decisions regarding service delivery.
However, we found gaps in infection prevention and control and environmental risk assessments. Also, governance systems and audits were not effective in identifying gaps in maintenance, fire safety and stock checks. This posed a risk to infection prevention and control management and the environment. Although, the registered manager was proactive responding immediately to our concerns to ensure the safety of staff and services users.
There was one breach in regulation relating to good governance.