Women's Scan Clinic

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This is the first assessment for this service since registration in January 2022. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

We scored the service as 1. The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The service did not have a shared vision and strategy. There was no information available for women or staff describing the service's vision, values, or strategy. Although the service had a small team and may have relied on informal communication, there was no documented vision, values, or strategy, and no evidence these had been formally communicated. There was also no evidence of staff meetings or other internal communication arrangements that demonstrated how a shared understanding of the service's vision and values was promoted.

We scored the service as 2. The evidence showed some shortfalls. Although there was compassion for women using the service, there was little understanding of how the service should be run safely and effectively. There was insufficient evidence of continuous professional development for the leader.

The registered manager had not accessed appropriate support and development in their role. They were a trained sonographer and carried out some of the scan appointments and understood the provision of the ultrasound practice well. However, they had not taken part in continuing professional development to keep up to date with new guidance or protocols.

There were insufficient levels of communication between the staff who did not get together regularly. Although they worked within the service and were visible to women during appointment sessions, only one sonographer worked at a time. There was no evidence of regular meetings or other opportunities for the registered manager to engage with staff, such as sessions working alongside the second sonographer.

We scored the service as 2. The evidence showed significant shortfalls. There was no clear process to gather feedback and learn from it.

The service did not foster a positive culture where women could speak up and have their voice heard. There was no clear process for collecting feedback from women or people accompanying them. There was an option for women to provide feedback through online reviews. Although the service read these reviews and sometimes responded, staff did not collect or review the feedback in a structured way.

When feedback was received the service did not openly share any lessons learned or actions taken. The service did not have records of how many feedback comments were received or whether they were positive or negative. There were no staff meeting minutes, so no record to show whether staff discussed feedback. There was no evidence that the service used people’s feedback to learn or improve.

A culture of speaking up by staff was supported by a policy. The service sent their whistleblowing policy after the onsite inspection. This policy was in date, but we did not see any evidence that it was accessible to staff in the service as it was saved on the manager’s laptop.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. Leaders worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service worked towards an inclusive and fair culture for the staff employed by them. They had a small staff team consisting of the registered manager, a sonographer and a phlebotomist. After our onsite visit, the manager sent us an ‘equality, diversity and inclusion statement – workforce’, which was due for its next review in December 2026. The statement set out the service's commitment to equality, diversity and inclusion, including fair employment practices, reasonable adjustments, and arrangements for reporting and addressing concerns. However, there was no evidence to show how this was applied in practice.

The registered manager supported reasonable adjustments to accommodate the work-life needs of their staff. Staff worked flexible hours to match booked appointments, but they could block out time or change the appointment schedule if they needed to make personal arrangements.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. Staff did not act on the best information about risk, performance and outcomes.

The service did not have effective governance systems to provide assurance that care was safe, effective and well managed. Governance arrangements had not identified or addressed concerns relating to safeguarding training, consent processes, infection prevention and control, policy review or quality assurance. Several policies and procedures were out of date and had not been reviewed in line with current national guidance.

Professional indemnity arrangements did not cover fetal and pregnancy scanning. These services were subsequently suspended during our onsite visit, which was confirmed in writing by the registered manager.

The provider had not established a structured programme of audit or quality review. Leaders could not be assured that risks were consistently identified, mitigated and monitored. Although some isolated audits were submitted, these did not demonstrate an effective system for monitoring quality, outcomes or compliance.

We scored the service as 3. The evidence showed a good standard. The service understood the duty to collaborate and work in partnership, so services worked seamlessly for people. However, there were limited opportunities in a small service to share information and learning with partners and collaborate for improvement.

As a small service with one speciality, there were limited opportunities to work with the community. However, the organisation was connected with other services if women required onward referrals. The service had not needed to explore the scope for more collaborative working with other organisations.

We scored the service as 1. The evidence showed significant shortfalls. The service did not focus on continuous learning, innovation and improvement across the organisation.

The service did not support a focus on continuous learning, innovation and improvement. There were no systems or processes to routinely record, monitor or review outcomes, or to benchmark performance against recognised national frameworks, such as the British Medical Ultrasound Society (BMUS) audit tool.

There was no governance framework to ensure incidents, complaints and feedback was reviewed to identify learning.