Archived: HeartScan Ltd

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• 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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that the service proactively collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to requires improvement. This meant the service management was inconsistent.

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.

The evidence showed a good standard. The service had a clear vision, and a strategy to turn plans into reality

The service had a vision ‘to be recognised and acknowledged as the ‘leading diagnostic clinic for cardiac interventions in the North of England’ and had plans to turn it into action.

The service undertook initiatives to improve engagement and promote the service in a way that met patients’ needs. The strategy and supporting objectives were achievable with the aim of providing a distinctive, specialist, highly professional, high quality, reliable and value for money customer focused service that exceeded people’s expectations.

There was a delivery plan that included a strong focus on collaboration with current and potential service users to expand the service while delivering and improving quality of care and people’s experiences.

The evidence showed a good standard. The registered manager understood the context in which the service delivered care, treatment and support.

The registered manager had a range of experience, skills and abilities to run the service, and understood the context of service delivery.

The registered manager was not based at the service every day the clinic was operational. However, they conducted pre-assessments of all patients remotely over the telephone, and attended the service approximately every 2 weeks, to assess for themselves how the service was running and to meet with staff. They were easily contactable by telephone if required to be onsite.

Staff we spoke with told us the registered manager was approachable and they felt supported. The registered manager took their role seriously and knew how to deal with concerns when raised which promoted a positive culture in the service.

The service’s statement of purpose was under review at the time of our visit.

The ratings poster from our previous inspection was not displayed. However shortly after our assessment, the registered manager provided a photograph of the poster on public display.

The evidence showed a good standard. The service fostered a positive culture where patients and staff felt they could speak up and their voice would be heard.

The receptionist gave all patients a feedback form to share their experiences and provide their views about the service. In addition, people could leave feedback by completing a form on the service’s website. All feedback we saw was positive and concurred with the experience of patients we spoke with. The registered manager shared the feedback with staff, and they saw it as an opportunity to improve.

The service had a whistleblowing policy and staff felt empowered to challenge one another if needed. The policy included signposting to external bodies under the Public Interest Disclosure Act 1998.

The evidence showed some shortfalls. The service could not demonstrate how it valued diversity in their workforce.

The service had an equality and diversity policy. However, the recruitment process and associated documentation was not comprehensive, not all staff had completed training in equality, diversity, inclusion and human rights, and the service had not undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

This meant the service could not demonstrate how its focus was always on those with protected characteristics under the Equality Act and those from excluded and marginalised groups.

However, staff we spoke with told us they had everything they required to do their job.

The evidence showed significant shortfalls. The service did not demonstrate clear responsibilities, roles, systems of accountability and good governance.

The registered manager was the named person with responsibility for oversight of governance. However, the service could not demonstrate it operated effective governance systems and processes to assess, monitor, and drive continuous improvement in the quality and safety of the service.

For example, although the service had an operational risk register, the provider did not have oversight and awareness of risks we identified during the assessment. These included, but were not limited to, lack of comprehensive policies, variable staff training compliance, appropriate DBS checks, consistent recruitment processes, environmental and equipment safety check recording, audit activities and comprehensive cleaning records.

Although we saw risk of disruption to business continuity was on the risk register, there was no comprehensive business continuity plan (BCP) in place. A BCP is a reactionary guide detailing exactly how the service will maintain operations, communicate with staff, and recover if an actual disruption occurred.

However, the service was registered with the Information Commissioner’s Office, and all electronic and paper records were held securely, in accordance with General Data Protection Regulations (GDPR) principles.

The evidence showed a good standard. The service understood its duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information with partners and collaborated for improvement.

The service engaged and collaborated with relevant external stakeholders and agencies to improve care and treatment. For example, GPs and sports academies. It engaged openly with patients and sport organisations, to plan and manage services.

They communicated results to patients, GPs and other referrers in a timely way.

The registered manager described plans to explore NHS insourcing, which involved bringing their staff into NHS services to treat patients using the NHS’s own facilities, typically during evenings and weekends. This would help NHS services to clear backlogs without disrupting core services.

The evidence showed good standards. The service aspired to continuous learning, innovation and improvement.

The service was registered as a trademarked brand and was part of an interconnected regional network, which aimed to drive technology and local entrepreneurship.

They worked towards a government-backed accreditation scheme designed to help organizations protect themselves against common cyber threats and had invested in a new, secure private IT server.

The service planned to achieve British Society of Echocardiography (BSE) Echo Quality Accreditation (BSE EQA) in 2027. This is a framework designed to ensure clinical departments meet high standards for patient care and continual improvement.