Women's Scan Clinic

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

This means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service since registration in January 2022. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. Staff did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Safety was not a top priority that involved everyone, including staff and women. The service was unable to demonstrate a consistently embedded learning culture. There was no policy or procedure to support the reporting, review or learning from incidents or safety events. Governance documentation had largely not been reviewed since 2020–2022.

Incidents and complaints were not reported or investigated. There was no evidence of a structured process for recording or responding to incidents. There was no process for identifying themes, sharing learning, or implementing and monitoring actions. Learning was not formally discussed or recorded within meetings. There were 3 incidents reported in the 12 months before our inspection. The service did not provide evidence of how these incidents had been investigated, although brief ‘lessons learnt’ were noted.

There was insufficient evidence to show safety was taken seriously. Should there be a safety incident or complaint, it was unclear how lessons would be learned and changes made to improve the service. Without a clear reporting process and culture, there were concerns that risks to safety for women, staff, or others would not be recognised or acted on.

We scored the service as 3. The evidence showed a good standard. Staff made sure there was continuity of care, including when people moved between different services.

Continuity of care was a priority when women were referred to other services. For example, if urgent referral to another service was required, such as an NHS Early Pregnancy Assessment Unit (EPAU), the sonographer made a telephone referral and provided copies of the scan images and report. This communication helped the referral service and the woman by providing information in advance.

We scored the service as 1. The evidence showed significant shortfalls. Staff did not understand their responsibilities to help protect people and therefore did not have adequate training or procedures.

The service did not have clear systems, processes and practices to protect women from abuse. Some staff at the service were not adequately trained in safeguarding. Although the service did not offer appointments to people aged under 18, both sonographers confirmed children could accompany adults to their scan appointments. A review of training records confirmed the registered manager had completed safeguarding adults’ level 3 training in 2024, and safeguarding children level 3 in 2020. The second sonographer had only completed Level 1 in both adult and children’s safeguarding in 2026. All health care staff who encounter children and young people within their service, but do not provide direct clinical care to children and young people, are expected to have level 2 competencies. There was no evidence of safeguarding training for another staff member who worked occasionally for the provider. The children and adults safeguarding policies had not been updated since February 2020 and the policy did not include how often safeguarding training should be undertaken.

The service had not completed any risk assessments to cover children accompanying women to their appointments. Therefore, there was no consideration of potential risks regarding the lack of oversight of children if they were unable to remain in the scanning room, for example during a trans-vaginal scan.

There was some evidence of a recognition of the need to safeguard women. During the inspection there was some evidence of good practice when we saw concerns about a woman’s mental wellbeing were raised with their local hospital as a safeguarding concern.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks.

The service did not always inform women about risks relating to their care and treatment. During an observed appointment, a woman underwent a scan despite having another scan scheduled the following day. Potential risks associated with repeated scanning were not discussed and consent was not completed until after the procedure.

There were no risk assessments to address different scenarios or specific care needs. For example, no risk assessment had been completed for situations where a woman attended a scan appointment with a young child, including the potential risks associated with a child being present in the scan room during the procedure. In addition, there was no risk assessment to support women who required a chaperone while accessing the service.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service did not clearly identify or manage risks. There was no evidence of service-specific fire evacuation procedures, COSHH risk assessments, or contingency plans for the loss of essential utilities. The service was located off a main corridor, with a shared waiting area in the corridor and neighbouring rooms occupied by physiotherapy services. Consequently, the service had not adequately identified, assessed and mitigated all risks associated with the premises and service delivery. There was safety checks carried out for equipment., Equipment had been appropriately maintained, serviced and subject to electrical testing for safety by a trained professional.

We scored the service as 1. The evidence showed significant shortfalls. Leaders did not always make sure staff received effective support, supervision and development.

The service’s recruitment processes were not consistently followed. Although a recruitment checklist was available, it had not been used consistently. As a result, staff records were incomplete and varied in quality, with one record lacking evidence of references and photographic identification.

There was insufficient evidence to show training was up to date. The service did not maintain a training matrix and could not demonstrate that staff training was up to date or identify when refresher training was due. Mandatory training requirements had not been clearly defined, and the service did not have an effective system for monitoring training compliance. While some training records were available, the service could not demonstrate all staff had received the training necessary to carry out their roles safely and effectively.

The service could not evidence all staff were suitably experienced and competent. The service did not have appropriate arrangements to ensure access to a trained and vetted chaperone. Staff told us they would ask neighbouring physiotherapists or reception staff to undertake the role if required. There was no evidence to show that any chaperone used had received appropriate training or recruitment checks.

We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. Staff did not detect and control the risk of it spreading.

The service did not have an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. Staff did not have a comprehensive infection prevention and control (IPC) framework. There was no IPC policy, and staff had not completed IPC audits or risk assessments.

The scan room environment did not fully reflect national infection prevention and control guidance. There was expired stock, including probe covers and cleaning products, and some items could not be identified because labelling was not in English.

The service did not adequately identify and manage infection prevention and control risks. Women undergoing scans were provided with blankets that staff told us were laundered at home, but there was no policy describing how they should be used, cleaned or stored. It was unclear whether blankets were intended for single use or reuse between women. In addition, the service did not always follow its own procedures for clinical waste disposal, and infection risks were not consistently managed.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.