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Show your Bump Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 July 2019

Show Your Bump is operated by Mrs Wendy Ann Williams.

The service provides pregnancy keepsake scans to self-paying members of the public. These are trans abdominal scans, including 2D, 3D and 4D baby keepsake scans and gender scans. The clinic does not provide diagnostic scans.

The service is based in Wigan and in addition to the manager it employs one full time sonographer; one full time receptionist and three part time receptionists.

The clinic has a waiting room and reception area; a scanning room; a small private room for women to use if required; a toilet; and a small kitchen area. Souvenir items such as teddies and keyrings were displayed in the reception area.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 1 May 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by Show Your Bump was baby keepsake scanning.

Services we rate

We rated this service as Requires improvement overall because:

  • Staff did not complete mandatory training appropriate for their roles.

  • Staff did not always understood how to protect patients from abuse but they knew how to contact other agencies to raise any safeguarding issues.

  • The service did not have suitable premises or use appropriate control measures to manage the risk of infection.

  • The provider did not have clear operational policies for the service in place, or a system to ensure these were followed by all staff.

  • The service did not have systems to identify risks, or plans to eliminate or reduce them.

  • Leaders were not always aware of the risks, issues and challenges within the service and during inspection we identified risks which had not been previously recognised. This included risks in infection prevention and control, consent and in safeguarding systems.

  • There was no process to review key items and a strategy, values or governance framework was not identified.

However;

  • Equipment was maintained in accordance with manufacturers’ guidance.

  • Staff kept appropriate records for service users and stored these securely.

  • Staff treated service users with dignity and respect and involved service users and those close to them in decisions about their care.

  • The service engaged with customers and staff and took action to improve the service provided.

  • The manager promoted a positive culture that supported and valued staff.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with seven requirement notices for the service. Details are at the end of the report.

Name of signatory

Ellen Armistead

Deputy Chief Inspector of Hospitals (Hospitals North)

Inspection areas

Safe

Requires improvement

Updated 15 July 2019

We rated safe as

Requires improvement

because:

  • Staff had not completed mandatory training relevant for their role.
  • Staff did not always understand how to protect service users from abuse.
  • The service did not always control infection risk well and did not always use control measures to prevent the spread of infection.
  • There was no sink within the toilet facilities or hand washing facilities in the scan room.

However;

  • Ultrasound equipment was maintained in accordance with manufacturer’s guidance.
  • The service ensured there was always a member of staff trained in first aid available during opening hours.
  • The service kept records of referrals for cases where an abnormality or concern had been identified.
  • Staff kept appropriate records of care for service users, and stored records securely.

Effective

Insufficient evidence to rate

Updated 15 July 2019

We did not rate effective because we do not have enough information to make a judgment. We found:

  • Sonographers completed peer review of their practice.

  • Women were advised about the need to drink water prior to their appointment.

  • The service had a resource folder for staff containing details of early pregnancy flow charts and NHS guidance.

However:

  • There was no induction process for new staff.

  • The service did not have a policy and staff had not completed training regarding the Mental Capacity Act.

Caring

Good

Updated 15 July 2019

We rated caring as Good because:

  • Staff cared for service users with compassion and respect.

  • Staff ensured women were comfortable during their appointments and protected their privacy and dignity.

  • Staff were aware of women’s emotional needs and supported them professionally when they needed to communicate any concerns identified.

  • Staff involved women and those close to them in decisions about their care.

Responsive

Requires improvement

Updated 15 July 2019

We rated responsive as Requires improvement because:

  • The service did not always take account of people’s individual needs.

  • The service did not have an effective and accessible system for identifying, receiving, recording, handling and responding to complaints by service users.

However

  • Appointments allowed sufficient time for service users to understand information and select their scan pictures.

  • People could access the services at a time convenient to them.

  • The service received positive feedback from service users and any concerns were investigated.

Well-led

Inadequate

Updated 15 July 2019

We rated well led as Inadequate because:

  • Although there was an overall aim to develop the service, there was no strategy or plan documented to progress this.

  • There were no formal governance arrangements in the service and policies related to service activities were not clearly identified.

  • The service did not have effective recruitment processes.

  • The service did not have arrangements in place for identifying, recording and managing risks. Leaders were not always aware of the risks, issues and challenges in the service.

  • There was no process to review key items and a strategy, values or governance framework was not identified.

However;

  • There was an open and transparent culture within the service; all staff we spoke with were passionate about the service and proud of their work.

  • The service engaged well with service users and staff.

Checks on specific services

Diagnostic imaging

Requires improvement

Updated 15 July 2019

We rated this service as requires improvement because the service required improvement in safe and responsive, was inadequate in well-led, but it was good in caring.

We inspected but did not rate effective.