Womb With A View Grimsby

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• 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 systems were safe, people were protected from abuse and avoidable harm, the service managed risk, the environment was well maintained, the service had enough qualified staff and infection control was managed well.

This is the first assessment of the service and the rating for safe is good. Patients were safe and protected from avoidable harm.

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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learned to identify and embed good practice.

The service had an incident reporting process. Staff knew what incidents to report and how to report them. Staff had access to electronic systems for ease of access to policies, procedures and standard operating guidance.

The service had not reported any notifiable safety incidents or never events in the previous 12 months. A never event is a serious, preventable safety incident which should not occur if the available preventative measures are followed. Examples of more minor incidents and accidents were logged and reported identifying any learning and actions required. We reviewed incident records and found investigations had taken place, actions had been highlighted and learning had been used to improve service delivery. Recent examples of incidents included an obstructed emergency exit noted during a routine inspection, which led to additional safety checks and revisions to standard operating procedures and audit processes. Another incident involved a misunderstanding of the services provided, resulting in changes to the website and consent forms, together with the introduction of a staff script to support consistent communication and understanding.

Staff demonstrated a good understanding of the duty of candour and described a culture of openness and honesty. They explained how they would provide people and their families with explanations, apologies and support if things went wrong. Staff told us they felt able to raise concerns and were confident concerns would be listened to and acted upon appropriately.

Staff told us they supported one another following difficult or distressing appointments and felt able to discuss concerns openly with the registered manager. Staff described informal debriefing following emotionally challenging situations and said additional support was available when required. The registered manager also maintained professional links with other ultrasound providers and used these relationships to discuss developments within the sector, share learning and identify opportunities for service improvement.

Due to the small size of the service and the low number of incidents reported during the previous 12 months, opportunities for formal learning reviews and trend analysis were limited. However, leaders reviewed incidents and safety concerns proportionately and used learning to support improvements in service delivery.

The service worked with people and healthcare partners to establish and maintain safe systems of care. Arrangements were in place to support continuity of care and ensure people could access further assessment and support when required.

People accessed the service through self-referral and booked appointments directly with the provider. The referral and booking processes ensured sufficient information was obtained to determine whether the service was appropriate and whether people's needs could be safely met. Staff gathered relevant information during booking and worked within defined inclusion and exclusion criteria. Staff clearly explained that private scans and screening tests supplemented, rather than replaced, routine NHS maternity care and encouraged people to continue attending NHS appointments and scans.

The service followed relevant professional guidance, including the British Medical Ultrasound Society (BMUS) Pause and Check principles. The clinic used both formal and informal image quality review for quality assurance and professional development. The registered manager monitored compliance with scan protocols and professional standards through audit activity, including audits of sonographer practice, scan quality and clinical documentation.

Information was shared with external services, with the person's consent, to support continuity of care where appropriate. The service had established pathways for escalation and onward referral when abnormalities were identified. Staff demonstrated a good understanding of referral pathways and described positive working relationships with local maternity services.

Referrals and escalations were recorded within patient records and monitored through a referral and escalation tracker. Record details included the reason for referral, receiving service, level of urgency, actions taken and follow-up information where available. This enabled leaders to monitor referral activity and review referral outcomes where these became known.

Where direct referral arrangements were not appropriate, staff signposted people to the most suitable healthcare service, such as their maternity team, GP, NHS 111 or emergency services, and recorded the advice provided. Staff ensured people understood the recommended next steps.

The service worked with people and healthcare partners to protect people from abuse, neglect, discrimination and avoidable harm. Staff understood their safeguarding responsibilities and demonstrated a clear understanding of how to identify, respond to and report safeguarding concerns.

The registered manager acted as the safeguarding lead for the service and maintained oversight of safeguarding activity. All staff had completed safeguarding training appropriate to their roles and demonstrated a good understanding of their responsibilities to protect people from abuse and improper treatment. Although there had been no safeguarding cases or concerns reported during the previous 12 months, staff were confident in describing how they would recognise, respond to and report safeguarding concerns. The service had previously contacted local safeguarding teams for advice when required.

The service had an up-to-date safeguarding policy which included contact details for local authority adult and children's safeguarding teams, together with guidance on recognising and reporting concerns. Safeguarding flowcharts were displayed within the clinic, and information about abuse and how to seek support was available within the service.

Staff demonstrated an understanding of how to recognise adults and children at risk of abuse, neglect, discrimination or exploitation, including people with protected characteristics under the Equality Act. They described how they would identify concerns, escalate them appropriately and work with healthcare partners and other agencies to keep people safe. Staff were aware of issues relating to domestic abuse, modern slavery and female genital mutilation (FGM). They told us FGM awareness formed part of their safeguarding training, and the service maintained guidance to support staff in recognising and responding to concerns.

Although the service was registered to provide care for adults aged 18 years and over at the time of inspection, leaders had considered the safeguarding and consent arrangements that would be required should younger people attend the service in the future. Policies included guidance regarding consent, identification checks and the involvement of parents or guardians where appropriate.

Staff understood that safeguarding concerns could override confidentiality where there was a risk of harm and described how they would seek advice and share information appropriately. Safeguarding audits provided assurance that safeguarding arrangements, training and procedures remained effective, and actions identified through audit activity were monitored through governance processes.

The service carried out Disclosure and Barring Service (DBS) checks for staff and maintained oversight of recruitment and safeguarding records. One member of staff was awaiting renewal of their DBS certificate at the time of inspection, and an appropriate risk assessment was in place whilst awaiting the updated certificate.

Chaperone arrangements formed part of the consent process and staff followed a chaperone protocol. Chaperones were routinely present during transvaginal examinations. Additionally, these arrangements supported people's privacy, dignity and safety during intimate examinations.

The service had a lone working policy, although staff told us they did not routinely work alone.

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.

Staff gathered information before appointments to identify individual needs and any factors that may affect care. This included information about communication needs and mobility requirements. Where risks or additional needs were identified, staff used this information to plan care and make reasonable adjustments.

Staff communicated effectively with people to ensure they understood the scanning process and the care being provided. They explained procedures, obtained informed consent and adapted communication where additional support needs were identified. Translation services were available when required.

The service had clear consent processes which supported people to make informed decisions about their care and treatment.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The facilities met the needs of people using the service and those close to them. The premises included a reception area with comfortable seating, access to complimentary hot and cold drinks, a dedicated scan room and a separate consultation room which staff used for venepuncture, private discussions, longer appointments or when additional support was required. A small play table area was provided for young children.

The premises were visibly clean, tidy and well maintained throughout. Staff completed daily room checks and maintained cleaning schedules. 'I am clean' stickers were present on equipment and had been completed and dated appropriately.

The service had implemented additional cleaning and monitoring arrangements for some decorative items and soft furnishings within the clinical environment to minimise dust accumulation and support effective infection prevention and control.

The design, maintenance and use of the premises supported the delivery of safe care. The environment followed relevant guidance relating to healthcare premises and provided appropriate privacy and security for people using the service.

Bathroom facilities were adapted for disabled access, including an emergency assistance call system.

The service identified and managed environmental risks. Fire exits were accessible, clear and unobstructed at the time of inspection. Fire extinguishers were in date and subject to regular checks. The service maintained a fire risk assessment and fire safety policy, and routine fire safety checks were undertaken. The provider also maintained appropriate insurance and business continuity arrangements to support service resilience in the event of an emergency.

The service maintained equipment and resources to support safe care and effective emergency response. Emergency equipment such as first aid and spill kits was readily accessible, and staff knew how to obtain assistance in an emergency. Staff were aware of the location of the nearest defibrillator and how to access it if required. There was always a trained first aider on duty. The registered manager had also completed emergency scenario training as part of their university sonography programme, which supported their ability to respond effectively to a range of emergency situations.

At the time of inspection, we found the Control of Substances Hazardous to Health (COSHH) cupboard did not meet the specifications expected of a COSHH cupboard. For example, cleaning equipment was stored alongside substances hazardous to health. Following the inspection, the registered manager acted promptly to address these concerns and introduced a dedicated COSHH-compliant cupboard.

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 workforce consisted of the registered manager and two part-time sonographers, one of which was the clinical lead. The registered manager had overall responsibility for the day-to-day management of the service and undertook reception, administrative and phlebotomy duties. They had completed appropriate phlebotomy training and competency assessments and were also completing a university sonography programme. This staffing model supported continuity of care and ensured people had access to appropriately qualified staff.

Staff told us they worked well together and provided mutual support to ensure appointments could be delivered safely and effectively. Where a staff member was unavailable, arrangements were in place to provide cover and maintain service provision.

The registered manager had oversight of staffing, recruitment, qualifications, professional registration and training. The service maintained records of staff qualifications, right to work documentation, DBS checks, professional registrations and mandatory training through personnel files and a training matrix. At the time of inspection, all staff had undergone appropriate pre-employment checks to ensure they were suitable for their roles.

Staff completed mandatory training relevant to their roles and the service monitored completion to ensure training remained current.

The service had an induction programme for new staff. This was supported by an induction checklist covering areas such as fire safety, infection prevention and control, policies and procedures, and local working practices. Staff completed competency assessments appropriate to their roles.

The service reviewed staff competencies and development needs on an ongoing basis. Sonographers participated in peer review audits of scan quality every three months, co-ordinated by the clinical lead and themes were reviewed at governance meetings to provide assurance regarding clinical standards and maintain professional competence. Staff told us they had opportunities to access additional training and continuing professional development relevant to their roles.

Staff described positive working relationships within the team and told us they felt supported in their role. The registered manager received monthly supervision to support their professional practice and service responsibilities. The service completed annual appraisals for staff and planned to increase the frequency of these discussions to six-monthly reviews to further support development, performance and objective setting.

The service assessed and managed the risk of infection and had systems in place to detect and control the spread of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The registered manager acted as the infection prevention and control lead and had completed relevant training to support effective oversight. Monthly infection prevention and control audits, alongside hand hygiene audits, provided additional assurance regarding cleanliness and compliance with infection prevention and control procedures.

Staff adhered to infection prevention and control principles. Personal protective equipment and hand gel were available throughout the service, including in clinical and waiting areas. Staff maintained equipment to an appropriate standard and cleaned it after each use. The examination couch and disposable couch roll were changed between people, and staff decontaminated ultrasound transducers, including transvaginal probes, in line with service procedures. Cleaning schedules covered the ultrasound machine, scanning equipment and clinical environment.

Staff used single-use sterile ultrasound gel where required and stored gel products appropriately. We saw no evidence that gel was decanted from larger containers, and opened products were dated to support stock control and monitoring of expiry periods.

Decorative items, including artificial floral displays, were present within the clinical environment. The service had considered the potential infection prevention and control risks associated with these items and had implemented cleaning and monitoring arrangements to minimise the risk of contamination. The most recent infection prevention and control audit was comprehensive and demonstrated 100% compliance.

A fabric privacy curtain was in use and the service maintained a documented laundering schedule. Records confirmed laundering had taken place as scheduled and when required. The scan room was also fitted with an air purification system to support environmental cleanliness alongside routine cleaning, inspection and laundering arrangements.

The service had established arrangements with an external contractor for the collection and disposal of clinical waste and sharps. Staff segregated waste correctly, and sharps bins were clearly labelled and dated. These arrangements supported the safe management and disposal of waste.

At the time of inspection, we found clinical waste was not securely stored. The registered manager took immediate action to rectify this concern ensuring that all clinical waste was stored securely in line with Environment Agency guidance.

The service maintained a water safety risk assessment and operated a water hygiene programme, including routine flushing of outlets and monitoring of water quality risks. Due to the low-risk nature of the water system, routine Legionella sampling was not required.

Blood samples were stored in accordance with laboratory instructions and dispatched on the day of collection. Arrangements were in place to manage delays or concerns regarding sample suitability.

The service did not hold any medicines. We did not score this quality statement.