Cocoon Harrogate

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This is the first assessment for this service. This key question has been rated good. This meant women’s outcomes were consistently good, and women’s feedback confirmed this.

We looked for evidence that women had the best possible outcomes because their needs were assessed. We checked women’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring women were at the centre of their care. We looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service did not always make sure women’s care and treatment were effective because they did not always check and discuss women’s health, care, wellbeing and communication needs with them.

Women told us the booking information provided all the information they needed, including how to get to the service, what preparation was required, and what to expect during the scan.

The service told us health screening was undertaken throughout all visits. However, the Registered Manager told us there was no formal mental health assessment process or mental capacity assessment process despite a policy position regarding women lacking capacity. The Registered Manager said there was no structured assessment of infection risks before attendance. The service had no prompts in place for women when they first booked to identify if they had any additional needs.

We viewed 3 sets of notes via the electronic patient record which identified limited documented health assessment at women’s first visit.

We discussed this with the service and they recognised this was a gap which required a more structured format. They informed us following our on-site visit they had produced a pre-procedure health screening guideline. This assessment would cover infection prevention and control, physical safety, mental health and emotional wellbeing, capacity concerns, pregnancy-related clinical risks.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

At the time of inspection, the service did not have a formalised organisation-wide audit schedule. The service recognised this as a gap and acknowledged their audit programme had developed in an ad hoc manner rather than through a structured annual plan. They recognised their audit programme did not provide sufficient oversight across all aspects of the service, including areas such as documentation and record keeping.

To address this, the service planned to implement a governance tracker with an inbuilt audit schedule to identify all required audits, their frequency, responsible leads, and reporting arrangements.

Women told us staff had offered the use of a chaperone. However we did not see any chaperone posters displayed on site, and staff did not record in reports whether they had offered women the opportunity to have a chaperone present during their appointment.

We did not observe the use of chaperones for transvaginal scans despite the British Medical Ultrasound Society guidance, which stated a trained clinical chaperone needed to be present during transvaginal ultrasounds to protect both women and sonographer. We discussed this with the leaders who identified this was a gap. Evidence provided by the service after the onsite inspection identified a chaperone would now be present during all transvaginal ultrasound examinations. The service said they would undertake audits to provide assurance they followed guidelines.

The service had not undertaken any health records audit and therefore could not provide any assurance documents were up to date and contained the relevant information. The service recognised this as a gap in governance and aimed to roll documentation audits out as part of clinical audit and compliance monitoring.

The service used a Standard Operating Procedure (SOP) to ensure all women requesting to use the service were suitable and within the scope of their service. Scanning specific SOP’s were used to ensure scans were appropriate and safe, but there were no audits to evidence that these had been applied consistently.

The Registered Manager told us image audits and report audits were undertaken. We found audits were completed but outcomes were not routinely collated, formally reviewed, or shared through a structured governance process.

The service Ultrasound SOP manual contained all ultrasound protocols to support with safe, consistent and effective delivery of pregnancy ultrasound examinations. The Registered Manager told us the criteria used by sonographers to decide the best type of scan to use was based on professional judgement. She expressed uncertainty regarding whether clearly documented criteria existed and whether staff compliance was monitored.

The service ultrasound policy and quality assurance framework identified that staff should follow the ALARA (As Low As Reasonably Achievable) principle when undertaking ultrasound examinations. During our inspection, we observed an occasion where a transvaginal scan was undertaken when a transabdominal scan may have been sufficient.

We recognised that all staff undertaking ultrasound examinations were registered healthcare professionals and that decisions about the most appropriate scanning approach were based on their individual clinical judgement. However, the service had not undertaken a clinical audit of ultrasound practice or an audit of health records to assess compliance with the USS Policy. Therefore, leaders could not assure themselves that clinical decision-making and practice were consistently aligned with the service’s policy and the ALARA principle.

The Registered Manager told us there was an ultrasound equipment quality assurance programme in place, including daily visual checks, weekly checks and monthly quality assurance (QA) checks. However, QA records for ultrasound equipment were held locally rather than on a shared electronic system therefore there was limited evidence of daily checks. The service had recognised this was a risk and were in the process of rectifying it.

The Registered Manager peer reviewed her colleagues work to ensure diagnostic accuracy and maintain governance standards. The Registered Manager told us she would discuss with individual members of staff if she found any issues. However, the Registered Manager stored these audits on their computer and did not share or discuss the findings with the wider team through established governance processes to support continuous quality improvement, risk management, and the delivery of safe care.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the women, they had a good understanding of pathways and procedures.

Leaders told us the service received the results of blood tests undertaken as part of NIPT. Staff contacted women to discuss the results and then sent them a copy of the report.

The service worked well across teams and services to support women. They made sure women only needed to tell their story once by sharing their assessment of needs when women moved between different services.

We observed a good working relationship between staff and leaders.

The service worked closely with its midwifery partners and all information was shared between the two services. The scanning and midwifery services ensured they worked together to reduce visits by arranging appointment for both services within the same time period.

Leaders told us the service did not hold regular staff meetings as the majority of the clinical staff only worked one day a week and therefore it would be difficult for all staff to get together. Any information which required sharing was done on a one to one basis or via private massaging.

Staff told us they felt fully informed about the service. Staff told us how they would feedback any issues which arose via private messaging and how discussions were held and changes were supported.

The service supported women to manage their health and wellbeing to maximise their independence, choice and control. The service supported women to live healthier lives and where possible, reduced their future needs for care and support.

Women told us staff offered advice regarding health promotion whilst at the service.

The service could signpost women on to a personal trainer, yoga team, breath work service, nutritionist, weight management support services. Counsellors and bereavement services were also available.

The Registered Manager told us there was no formal process for providing lifestyle-health advice during scans.

The service routinely monitored women’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of women themselves.

Women told us staff were prompt at sending the results of scans and blood results to themselves.

The service used a private clinic to analyse and report any blood tests they had requested. The service told us they received results promptly via their secure electronic reporting system.

The service had produced policies to ensure safe and evidence based practice in their day to day working. The policies identified monitoring would be through audit and reviews. However, we saw no evidence of these audits and reviews and there was no feedback mechanism in the service to share these audits and reviews for learning and improvement.

Leaders told us the service did not review clinical outcomes data because of its size and the nature of the services it provided. However, the service planned to review all feedback as part of its new governance processes to provide an ongoing picture for discussion and documented evidence.

The service did not always tell women about their rights around consent and did not always respect their rights when delivering care and treatment.

Leaders told us staff obtained written consent once, at referral, and recorded it in the electronic records management system. Women were informed at this time of the proposed treatment along with potential outcomes or impacts of scanning. However, the service had not undertaken an audit of consent and could not confirm staff had obtained written consent from every woman. The service had recognised this was a gap in governance and planned to incorporate consent into a rolling programme of audits.

A consent policy was in place identifying it accepted women 18 and over with full mental capacity. Verbal date of birth was used to identify age and mental capacity was not assessed, therefore we were not assured that valid consent had been obtained.

Women told us they were asked for verbal consent at all times.

We observed staff gaining verbal consent for care and treatment at every opportunity.

The Society of Radiographers advised that best practice guidance for transvaginal scans required written consent immediately before the procedure. Where only verbal consent was obtained, a chaperone needed to witness the consent and staff needed to document it in the woman's record. However, the service obtained only implied or verbal consent and did not use a witness.

All staff had up to date training in disability awareness, including autism and learning disabilities but we found no evidence of Mental Capacity Act or Mental Health Act training.