30 July 2019
During a routine inspection
Baby Moments is operated by Baby Moments Limited. The service provides diagnostic pregnancy ultrasound, gynaecological and fertility scans and non-invasive prenatal testing to self-funding women predominantly across Oxfordshire and Berkshire but would accept women from across the UK.
The service provides diagnostic imaging for women aged 17 years and over. It is registered with the Care Quality Commission (CQC) to provide the regulated activity of diagnostic and screening procedures. It has one ultrasound machine with one waiting area.
We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 30 June 2019. We gave staff two working days’ notice that we were coming to inspect to ensure the availability of the registered manager and clinics.
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.
Services we rate
We have not previously inspected this service. At this inspection we rated it as Requires improvement overall.
We found the following issues that the service provider needs to improve:
- Although the registered manager had not received an appraisal they did appraise staff work performance annually and checked to make sure staff had the right qualifications for their roles.
- Although the service had policies that were current, and version controlled not all policies evidenced the latest national guidance.
- Ultrasound images were not independently reviewed to ensure they were of a good quality.
- The ultrasound machine was not password protected and therefore patient data was at risk of unauthorised access.
- The children’s safeguarding policy did not reference child sexual exploitation and female genital mutilation (FGM) and the sonographer did not have knowledge of FGM and what actions to take if discovered.
- The service did not have the proper kit to safely clear any blood spillages.
- Although staff were able to identify risks within the service, these were not documented or reviewed on a regular basis.
- The service did not have a robust governance process to provide assurance of the quality of the service delivered.
However, we found the following areas of good practice :
- The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care.
- Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
- The environment was appropriate and met the needs of the range of people who accessed the service, including toys for children to play with whilst waiting for parents’ appointments and the service controlled infection risks well.
- Women could access services and appointments in a way and a time that suited them. The service used technology innovatively to ensure women had timely access to ultrasound scans.
- The service collected, analysed , managed and used information to support all its activities
- The service treated concerns and complaints seriously. The registered manager completed comprehensive investigations and shared lessons learnt with all staff.
- The service improved service quality and safeguarded high standards of care by creating an environment for good clinical care.
- Staff were caring, compassionate, kind and engaged well with women and their families.
- The service took account of patient’s individual needs for example if an early scan showed a miscarriage, if possible staff would request the next patient go for a coffee while the women who had miscarried had time to absorb the findings.
- Managers promoted a positive culture that supported and valued staff. Staff reported their team worked well together and staff trusted and respected each other.
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 four requirement notice(s) that affected diagnostic and screening. Details are at the end of the report.