The Mary How Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question requires improvement. The service was in breach of legal regulation in relation to fit and proper persons employed and safeguarding service users from abuse and improper treatment. 

The service has made improvements and is no longer in breach of regulations. At this assessment the rating has improved to good.

We found the service had effective systems to keep people safe. Staff understood how to report incidents, protect people from harm, and provide safe care. The service had suitable facilities, equipment, staffing, and record-keeping arrangements. We identified some concerns with safeguarding training for managers and cleaning of some equipment and storage areas. The service addressed these concerns promptly following the assessment.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The service had a positive culture of safety, based on openness and honesty. They had systems to listen to concerns about safety and investigated and reported safety events. 

Staff knew what incidents to report and how to report them. They had completed training in incident reporting, had access to a current incident reporting policy and used an electronic reporting system to record incidents. Although the service reported no serious incidents in the 12 months before the assessment, staff could clearly describe the types of incidents they should report and the process they would follow. 

Leaders made sure staff received feedback from investigation of incidents, both internal and external to the service. Staff discussed feedback at team meetings and used it to improve practice. 

At the previous assessment, we found that not all staff understood duty of candour and the policy lacked clarity. At this assessment leaders and clinical staff demonstrated a good understanding of the duty of candour. Staff described how they would be open and transparent with patients and families and provide a full explanation if something went wrong. 

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. 

The service’s referral and admission processes ensured staff received all essential information to determine whether they could safely meet patients’ needs. Patients self-referred to the service by completing an online application form, telephoning the service, or attending the clinic on a walk-in basis. Staff then added patients to the waiting list for screening appointments. 

Staff worked with other healthcare professionals, with patients’ permission, to support continuity of safe care. Staff discussed screening test results with patients and only shared information with the patient’s GP where consent had been obtained. Staff signposted patients to other services following their screening appointment as needed.

Staff kept clear and detailed records of patients’ screening appointments. Records were complete, up to date, and contained the information staff needed to provide safe and effective care. Staff could access patient records easily when required.

The service stored records securely on an electronic records system. Staff used individual password-protected accounts to access the system, which helped protect patient confidentiality. Patient records were comprehensive and included all relevant information about screening tests, results, and follow-up actions.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Managers had completed safeguarding training to level 3, which was appropriate to their roles and responsibilities. This included responsibility for identifying and responding to safeguarding concerns, undertaking safeguarding processes, and making referrals to the local authority.  There had been no safeguarding referrals to the local authority in the 12 months prior to the assessment. Following the assessment, managers completed enhanced safeguarding training that was appropriate to their roles and responsibilities.

Staff were trained in Safeguarding Adults Level 2 and Safeguarding Children Level 2 and knew how to recognise concerns and make a safeguarding alert. Staff were able to describe how they protected people from harassment, discrimination and unfair treatment. They demonstrated an understanding of equality, diversity and inclusion and the importance of treating people with dignity, respect and compassion. Staff gave examples of how they adapted their approach to meet people's individual needs and preferences, including supporting people with protected characteristics under the Equality Act 2010. 

Staff understood the importance of promoting people's rights, choice and independence. They explained how they would challenge discriminatory practice, report concerns and escalate issues where people were at risk of being treated unfairly. Staff told us they received training in equality and diversity and felt confident supporting people to express their views, beliefs, culture, identity and relationships without fear of discrimination.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service involved people in managing risks to their health and wellbeing. Staff explained the purpose, benefits and limitations of screening tests before appointments took place, enabling people to make informed decisions about their care. The provider had clear inclusion and exclusion criteria to ensure people were appropriately selected for their preventative health screening service. Adults aged 18 years and over could access screening, while people who were pregnant, undergoing active investigations, or requiring diagnostic assessment for symptoms were excluded.

Staff discussed screening results with patients and provided information about any identified risks or abnormal findings. Where appropriate, staff signposted patients to other healthcare services or advised them to seek further assessment through their GP.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had suitable facilities, that met the needs of people using the service and aligned with national guidance. Patients could easily find and access the service, which provided private parking. The waiting area was bright, spacious, and had enough seating for patients awaiting appointments.

During the assessment, we reviewed evidence including fire risk assessments, portable appliance testing (PAT) records and checks of emergency equipment. We found these were up to date and subject to regular review.

The service had sufficient equipment to provide safe care. Staff carried out daily safety checks on specialist equipment. Staff used appropriately maintained equipment to undertake screening assessment, including an electrocardiogram (ECG) machine, blood pressure monitor, and weighing scales. External contractors serviced and calibrated nursing equipment annually, and records showed all checks were up to date. The manufacturer completed annual servicing of the ultrasound machine, and this was current.

Sonographers completed daily quality assurance and safety checks on the ultrasound machine, including checks for crystal dropout, plug damage, and sparking. These checks followed relevant professional guidance.

Staff disposed of clinical waste safely. They separated waste using colour-coded systems for general and clinical waste. Staff disposed of sharps, such as needles, in line with national guidance. The service had agreements for a specialist contractor to collect and dispose of clinical waste and sharps from secure external bins.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep patients safe. Managers did not use bank or agency staff because they felt continuity of care was better achieved with consistent staff. The service employed 8 nurses, 5 sonographers and 10 administration staff. If staff were absent at short notice, managers arranged cover from existing staff wherever possible. 

The service had 1 nursing vacancy at the time of the assessment. No staff had left the organisation in the 12 months before the assessment, and the service reported very low levels of both short-term and long-term sickness absence. Managers ensured that staff completed mandatory training relevant to their roles and the needs of the patient group using the service. Mandatory training compliance was approximately 88% overall. Most staff were up to date with mandatory training, with the small number of gaps relating mainly to new starters who were completing their induction programme and a limited number of outstanding modules. 

The lead nurse provided supervision and completed annual appraisals for the nursing team. The registered manager completed appraisals for administrative staff, and the chief executive appraised the registered manager. Sonographers did not receive appraisals from the service because they received these through their substantive roles in a local NHS trust. 

Managers made sure all staff completed an induction relevant to their role before working independently. The induction helped staff understand the service’s policies, procedures, and expectations, and ensured they had the skills and knowledge needed to carry out their duties safely and effectively. Staff told us they felt supported when they started work and had opportunities to familiarise themselves with their role, the environment, and the people they worked with. Managers monitored induction completion to make sure all staff received appropriate support when joining the service.

Managers encouraged staff to attend team meetings whenever possible. When staff could not attend, they had access to the meeting notes to keep them informed. Leaders kept clear and comprehensive meeting minutes, which were readily available to staff. This helped ensure important information and learning were shared consistently across the team.

Staff held the relevant professional registrations for their roles. Nursing staff were registered with the Nursing and Midwifery Council (NMC), and sonographers were registered with the Health and Care Professions Council (HCPC). The registered manager checked professional registrations regularly to make sure they remained current and staff were eligible to practise.

The evidence showed some shortfalls. Staff used equipment and control measures to protect patients, themselves and others from infection. However, we found some areas had not been cleaned effectively, which did not fully support the prevention and control of infection.

The service did not always keep equipment and storage areas clean. We found the ultrasound machines, ultrasound gel bottle holders, and the tops of clinical storage cupboards were not clean. We told the registered manager about this during the assessment. They arranged for these areas to be cleaned immediately and updated cleaning checks to reduce the risk of this happening again.

The service had up-to-date, version-controlled policies for infection prevention and control and the decontamination of medical devices. Staff maintained clean clinic rooms, waiting areas and toilet facilities. Nurses and sonographers completed daily cleaning tasks, including removing clinical waste, cleaning sinks, and disinfecting ultrasound probes.

The service contracted a cleaning company to clean the premises. Staff followed infection prevention and control procedures, including good hand hygiene and the use of personal protective equipment (PPE). Staff were bare below the elbows, cleaned equipment after patient contact, washed their hands appropriately, and wore suitable PPE when required. 

The service did not prescribe, administer, or store medicines, as this was not part of the service provided. Staff did not give advice about medicines or prescribe them.