Archived: HeartScan Ltd

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

We looked for evidence that safety was a priority for everyone, and that the registered manager embedded a culture of openness and collaboration.

We found recruitment processes did not meet national guidance. Disclosure and Barring Service (DBS) checks were not specific and relevant to the service. Not all potential risks in the care environment were sufficiently mitigated. Staff mandatory training, including safeguarding, was not always up-to-date.

However, the service had a positive learning culture and staff and patients could raise concerns. They assessed patient risks and made sure there was continuity of care, though effective record keeping. There were enough staff with the right skills, qualifications and experience to ensure high quality care and treatment. The facilities and equipment were visibly clean and well-maintained.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. Patients were not always 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 evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. The service listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well. There was an incident reporting and review policy, which reflected the service and national guidance. Staff recognised and reported incidents and near misses in line with the local procedure. The registered manager investigated incidents and shared lessons learned with the whole team.

The service had a ‘being open’ policy. The registered manager and staff understood what duty of candour meant.

The evidence showed a good standard. The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed. Staff made sure there was continuity of care, though effective record keeping and communication with patients, their GP and other referrers. The service had a policy to manage patients who became unwell.

Safety and continuity of care was a priority throughout people’s care pathway. The registered manager, risk assessed all patients who self-referred or were referred by their GP/other referrer, prior to booking procedures. They uploaded information to a secure electronic patient record, which was reviewed by clinical staff prior to undertaking procedures.

There was an admission criterion policy for patients. These criteria set out where there were limitations in services and therefore minimised risks by excluding some patients. For example, children under the age of 14, people who required blood tests, and cardiac stress-testing. Patients we spoke with told us they were given enough information to enable them to understand their procedure.

There were systems and processes to ensure the correct patients were treated and they only received the procedure which was intended. Suitably skilled and qualified staff undertook the required diagnostic procedures, in accordance with formal protocols.

Patient records were a mixture of electronic and paper documents, and were kept securely. The information technology (IT) connectivity was consistently available to meet the needs of staff who completed the records. The service had a policy which referenced appropriate guidance and legislation for management of records.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as the patient’s GP or NHS services, there was effective communication which allowed for seamless transfer.

The registered manager and staff had completed basic life support training in accordance with the service’s policy. The service had a first aid standard operating procedure, which provided guidance to staff in the event a person suddenly became unwell. It included cardiopulmonary resuscitation (CPR) guidance for adults and children.

The evidence showed significant shortfalls. Disclosure and Barring Service (DBS) certificates in all staff files were not specific and relevant to the service. The registered manager and staff had not completed all relevant safeguarding training appropriate to their role. There were no resources available to signpost patients to safeguarding help if they needed it. However, the service had up-to-date safeguarding policies, which reflected local safeguarding arrangements.

Disclosure and Barring Service (DBS) certificates in staff personnel files were not specific and relevant to the service. We discussed this with the registered manager at the time and after our assessment, received assurance that they had submitted new applications specific to this service.

The registered manager was the safeguarding lead for the service and had level 2 online safeguarding children and level 3 safeguarding adults training certification in their personnel file. There was no certification on file for the appropriate level of safeguardng training, as required in the Intercollegiate (2025) guidance, although the service was registered to provide regulated activities to children aged 14 to 17.

Staff completed safeguarding training provided by their respective substantive employers and submitted training records to the registered manager. However, not all staff had completed mandatory PREVENT (anti-radicalisation) and the appropriate level safeguarding children training modules for their roles.

Training records we received showed not all staff had completed learning disability and autism awareness training. Mandatory Training on Learning Disability and Autism became law in 2022 through the Health and Care Act 2022, with the legal requirement for CQC-registered providers to ensure staff received this training.

There were no posters or information at the service or on the service’s website, which staff could use to signpost patients to safeguarding help if they needed it. This meant there were missed opportunities to identify and act on potential safeguarding risks.

However, we saw up-to-date safeguarding policies, which reflected current national guidance for adults and children. All contained links to local authority safeguarding teams.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The registered manager kept a log to record local authority referrals, although the service had made none in the last 12 months.

The evidence showed a good standard. The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patients to do the things that mattered to them.

The service worked with patients to understand and manage risks. The treatment and care met patients' needs in a way which was safe and supportive.

The registered manager completed a pre-appointment check list prior to booking patients for procedures. It included the patient’s GP contact details and information about current symptoms, past medical history, social history, family history, medicines and any recent diagnostic tests and investigations. They uploaded this information to a secure electronic patient record, with associated referral information, to inform staff and the external reporting cardiologist.

We spoke with 4 patients during our assessment. All told us they felt listened to, risks were explained, and they were involved in decisions about their care and treatment.

The evidence showed some shortfalls. Although the service detected and controlled most potential risks in the care environment, environmental risk assessments and equipment safety checks were not always completed, for shared facilities and equipment used at the service. However, diagnostic and IT equipment, and technology supported the delivery of safe care. The clinical room was fit for purpose.

Although the service’s health and safety policy appeared to be in-date, the wrong person, a former director was shown as responsible for health and safety, waste management, incident reporting, first aid and risk assessment training, which was incorrect.

The service did not always manage environmental risks. For example, safety checks for equipment shared between the service and other providers who used the building, such as the first aid box and advisory external defibrillator (AED) located in the kitchen, were not documented. This meant we were unclear how the provider was assured that all shared equipment was always fit for use, for the service’s patients, when needed.

Although the provider had records to show that staff had completed fire awareness training provided by their respective substantive employers, there were no induction records or refresher training records in personnel files to demonstrate that all staff had completed a fire walk-through of the provider’s shared building. We requested but did not receive any fire evacuation drill records, which placed staff and patients at risk if an evacuation was required.

Shared fire extinguishing appliances and a fire blanket located in the kitchen were serviced within the last year. However, there was no fire extinguishing appliance in the clinical room, which was a concern we identified in our last inspection. There was no fire risk assessment to demonstrate how the service considered and mitigated this risk.

We received 2 documents titled ‘emergency procedures - fire and evacuation plan’. Neither document was dated or version controlled. The responsible person for ensuring fire risk assessments was different in each version.

There was a ‘hazard checklist’ document which identified environmental risks at the service However, this also included various risks which were not relevant or specific to the service.

There was a policy for managing medical devices, which detailed routine checks required for diagnostic equipment, to ensure that it continued to function correctly. These included pre-use checks, specified daily/weekly checks, reporting faults or damage and discontinuing use and battery charging. Whilst staff said they carried these checks out, there were no records to evidence this which in line with the service’s policy.

All cardiac diagnostic equipment we saw was in good order and serviced in accordance with the manufacturer’s instructions. Other equipment, in the clinical room, such as office equipment, seating and the examination couch, was provided by the building owner under the formal room rental agreement. All were in good order, visibly clean, and could be wiped clean after use.

The clinical room used for patient care reduced the risk of patient harm, and included for example, safe flooring and good lighting. Although there were no call bells, staff could summon assistance from other nearby staff, by shouting for help as needed.

The waiting area was uncluttered, bright and comfortable. Access to the building was monitored by a shared receptionist. They greeted patients on arrival, prompted them to complete their financial agreement and facilitated payment.

Fire exits were clear and free from obstruction. There were suitable toilet facilities to meet the needs of patients and their companions when necessary.

Items subject to the control of substances hazardous to health (COSHH) regulations, such as ultrasound gel, had an associated risk assessment and were stored appropriately when not in use.

The clinic had no designated parking spaces, although there was parking on the street outside the clinic or nearby. Parking was restricted to permit holders after 5pm.

The evidence showed significant shortfalls. The service could not demonstrate safe recruitment processes. The service could not demonstrate mandatory training processes were effective, and training did not fully meet the needs of the service, staff and patients. However, staff accessed effective support, supervision and development.

Although there was a recruitment and selection policy, it was not sufficiently comprehensive. The staff personnel files we reviewed did not contain documents such as interview records, references, photographic identification, signed job descriptions, and DBS certificates specific to the service. We brought this to the attention of the registered manager at the time. Following our assessment, they provided assurance they had taken steps to strengthen the policies and processes.

There was a staff appraisal policy, which described arrangements for new starters, including induction and mandatory training topics. However, we found induction records in only 1 of 3 staff files we looked at.

Mandatory training identified in the service’s policy was not sufficient to meet national guidance and did not fully meet the needs of the service, staff and patients. Mandatory topics included infection prevention and control (IPC), moving and handling, display screen equipment use, health and safety, information governance, safeguarding children (levels 1 and 2), first aid, basic life support and skills, and fire awareness. However, training records showed not all staff had completed, or were-up-to date with, all of these modules. Incomplete modules included IPC, first aid, moving and handling, and health and safety training.

The training policy did not include the requirement for safeguarding adults and safeguarding children to the required levels, PREVENT (anti-radicalisation), mental capacity act, equality and diversity, local fire arrangements, or learning disability and autism modules. In addition, the service could not demonstrate staff competency was checked, regarding use of specific medical devices at the service.

The registered manager informed us staff were all appropriately qualified and trained in their substantive roles. However, training policies did not reflect this, and the provider had no evidence to demonstrate staff were competent and up to date with these training modules.

The registered manager recorded staff training compliance on a training matrix. However, the document we received was not comprehensive or accurate. Some training was recorded as completed after our assessment and some modules were recorded as completed, although the date was in the future.

In addition, record of staff mandatory training completed in external substantive roles varied. Following our assessment, the registered manager provided some assurance that they were working to strengthen systems and processes.

The registered manager ensured they met with staff annually, to discuss performance. They had daily direct clinical access and support via telephone to a reporting consultant cardiologist, when required.

The evidence showed some shortfalls. Although visibly clean, the service could not demonstrate equipment and the environment were always cleaned, in accordance with the service’s policy.

Staff kept equipment and the premises visibly clean. However, there was no programme of infection prevention and control (IPC) audits, and no cleaning records. This meant the service was unable to demonstrate that the environment and equipment, including the laptop computer, diagnostic equipment, examination couch and equipment trolley were cleaned regularly in accordance with the service’s management of medical devices and IPC policies.

The provider showed us a blank IPC checks template, however, this included items of equipment not used at the service.

The clinical room was carpeted, and vacuumed daily, although not recorded when done. It was visibly clean and we saw it was professionally deep cleaned in August 2025. However, the IPC policy did not include how risks associated with carpets, such as spillage of body fluids, should be managed.

The provider was unable to demonstrate clear management responsibilities associated with the shared building, such as legionella safety checks. Although there was a policy, there were no records for flushing of water outlets.

Waste bins we saw contained appropriate liners for the domestic waste stream and disposal was managed under the formal room rental agreement.

All staff had completed mandatory IPC training which included hand hygiene. Staff told us how they cleaned their hands before and after each patient contact. We observed they had bare arms below the elbows, which ensured hands and forearms could be properly decontaminated.

Patients we spoke with told us they found the clinic to be clean and confirmed staff had used hand gel to clean their hands.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.