Updated 21 July 2025
We rated this service as good. We found a service where the manager was praised by all staff. Staff advised the manager was supportive and felt they could discuss issues and concerns openly. They supported an honest culture where staff felt valued and had opportunities for career development whilst being supported in their work/life balance. The service had effective systems and processes to ensure smooth pathways and transitions between providers. The manager ensured staff had sufficient competencies and training and the number of staff available kept women safe. The service provided women with positive outcomes and followed best practice to obtain women’s consent. Staff were kind and compassionate and ensured women and their families had numerous opportunities to ask questions. Women could be seen at times that suited them, including evenings and weekends, and there was no waiting list.
However, we found a breach of the legal regulations related to governance, Regulation 17. There was insufficient oversight of governance processes, which had the potential to cause harm. For example, translation processes did not follow best practice. Staff ‘unofficially’ translated to friends and family rather than via an official forum. This posed a safeguarding risk. Some policies did not follow best practice, for example, safeguarding policies did not provide guidance for referrals. Information was repeated between safeguarding children and adult policies that was not applicable. Complaint policies referenced sending concerns to the radiology union, which does not review complaints, there was no reference to the independent ombudsman. The service did not have a clinical sink in accordance with legislation ‘Health Building Note 00-09’. The risks associated with the site increased as the service provided invasive procedures. This was not risk assessed or audited to ensure the sink area was solely used for hand washing. Staff employment files were not fully compliant with recruitment requirements.