Baby Moments

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 leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating remains requires improvement.

The service was in breach of the legal regulation in relation to infection prevention and control. The clinic did not conduct sufficient clinical risk assessments. The clinic room had hard surface laminate flooring. We saw gaps in the laminate panelling in which dirt had collected. The clinic did not have all appropriate cleaning equipment to prevent cross contamination.

However, staff knew what to do in case of an incident, including the duty of candour. The service had clear guidelines for unexpected findings and onward management of patients. Staff made sure equipment, facilities and technology supported the delivery of safe care. There were enough qualified and competent staff to offer safe patient care. Staff’s knowledge was not always robust in terms of safeguarding situations.

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.

We scored the service as 3. The evidence showed a good standard. The service knew what to do in the event of incidents or accidents and how to share any learning with the team.

Staff understood what an incident and accident was and how to report it but there had not been any since 2019.

The service had an incident management and reporting policy in place, outlining staff roles in the event of an incident, and timelines. The policy referenced the duty of candour (the duty of candour is a requirement for health and social care providers to be open and honest with patients and their families when something goes wrong in their care that causes or has the potential to cause moderate harm or worse).

Staff told us the service kept an incident log but had not had any incidents for at least 2 years. We requested the incident log as part of our data request after the visit; however, we did not receive this.

The service had an accident book as part of the first aid kit. We saw the last accident was in 2019. This was recorded appropriately in the accident book.

This service was small, and it was easy for staff to discuss incidents or accidents as a team as soon as they occurred.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured all essential information about the patient was received to determine if the patient’s needs could safely be met.

Patients booked appointments online and answered basic questions on the booking form. The sonographer asked relevant health questions at the time of the appointment.

The service had a clear exclusion criteria policy. For example, they only saw women between the ages of 18 to 65. They did not scan patients who required sedation, or those with contagious diseases. All referrals were screened at the time of booking against these criteria.

Any patient not meeting eligibility was signposted to their GP, NHS 111, Early Pregnancy Unit(EPU), Foetal Medicine Unit, Gynaecology Department or Accident & Emergency (A&E) depending on clinical urgency. Staff kept a record of exclusion and onward referral on file.

The service had clear guidelines for unexpected findings and onward management of patients. This included referrals to the patient’s GP, the local EPU, or A&E. The sonographer explained they had an agreement with the local EPU: if something unexpected was seen on a scan, the sonographer called the EPU directly, with the patient present, to arrange a follow-up appointment. We witnessed this during our assessment.

We scored the service as 2. The evidence showed some shortfalls. Staff did not have a full understanding of how to identify people at risk of abuse. Staff did not always know what to do in safeguarding situations. They did not always share concerns quickly and appropriately.

All clinical and non-clinical staff received adult and children’s safeguarding training. Clinical staff completed level 3 training, and non-clinical staff level 2, which was in line with intercollegiate guidance (this is a framework that outlines the necessary knowledge, skills, and competencies for safeguarding children and adults). All staff were up to date with their safeguarding training. In addition, clinical staff completed annual female genital mutilation
(FGM) training.

The service had up-to-date adult and children’s safeguarding policies that included referral processes. Staff did not always know what to do in the event of a safeguarding situation, such as FGM or modern slavery. The sonographer also worked at an NHS trust and told us they would seek support from colleagues there. The clinic displayed a poster in the clinic room outlining safeguarding procedures for reporting concerns.

During our visit we reviewed the adult safeguarding policy, which stated the service used family members to interpret for patients whose first language was not English. Staff confirmed this is what they did even though an interpreting service was available. This was not considered good practice as it can breach confidentiality, can lack impartiality, and cause misinterpretation due to lack of medical knowledge. We asked for the safeguarding policy as part of our data request and the service had amended it to reflect our feedback.

Patients could bring their children to appointments. Reception staff monitored children in the waiting room if patients did not want to bring them into the scan room. However, this was not a recognised part of the receptionist’s job role, and the service did not have documented evidence of risk assessment and mitigation was in place to keep children safe.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. The service did not conduct clinical risk assessments. However, staff provided care to meet patients’ needs that was safe and supportive.

The clinic did not conduct clinical risk assessments, nor was there a schedule for clinical risk assessments in place. Clinical staff managed people’s emotions or distress in a positive way. A patient we spoke with confirmed this and they told us they attended this clinic because they felt supported.

If an emergency arose staff had access to a first aid box and items within were in date. The service shared a defibrillator with other on-site offices. Staff knew where it was stored and how to use it in the event of an emergency. All staff completed first aid and basic life support training.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Baby Moments operated from the first floor of an office building. Patients accessed the clinic via stairs or a lift. The service shared facilities with other offices. The clinic consisted of an open plan reception and waiting area, one clinic room, and a storeroom. All doors could be locked. The reception and waiting area environment was clean and tidy without clutter and had a welcoming atmosphere.

Equipment was suitable for the intended purpose and used properly. Clinical staff knew how to use scanning equipment safely. The service had a maintenance contract with an ultrasound repair service, and an engineer had visited in January 2025 to service the equipment. The ultrasound machine was password protected. The ultrasound machine included transvaginal (TVS) probes for internal examinations. The sonographer appropriately cleaned the probe before and after every scan.

The service had an environmental risk assessment schedule in place. An independent health and safety adviser carried out these assessments. We saw evidence this was conducted.

Fire extinguishers were located appropriately, serviced and full. Fire exits were clear.

We scored the service as 3. The evidence showed a good standard. 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.

There were appropriate staffing levels and skill mix to make sure people received safe care. The service was staffed according to the number of bookings for the day. One administrative staff member was on site during all opening hours and the registered manager, who was also the main sonographer, worked around the allocated appointments. The service had an arrangement with another sonographer who could cover appointments when required. The service did not use bank or agency staff.

The lead clinician was mostly present in the clinic. During any absence, a sonographer from a nearby trust covered appointments. The images taken during any absence were reviewed by the lead sonographer on their return. There was no evidence to show the substitute sonographer had their competencies assessed prior to starting work at the clinic.

The provider had a chaperone policy in place and printed information about the use of a chaperone was available to patients in the waiting room. Administrative staff acted as chaperone when requested. They had received appropriate training to fulfil this role.

There were robust and safe recruitment practices. We checked staff files and noted recruitment practices were in line with legislative requirements. All staff completed an induction that was tailored to their role.

Staff were up to date with their mandatory training. Training was provided through accredited providers, online learning platforms, or in-house sessions.

Staff received appraisals and we saw examples of non-clinical and clinical appraisals. Appraisals are important as they help staff reflect on their work and identify areas for improvement and development needs.

We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

Patients were not always protected from the risk of infection as some areas of the premises were not kept clean. Although the premises were cleaned weekly, the condition of some areas meant they could not be effectively cleaned and posed an infections control risk. The clinic room had hard surface laminate flooring. There were gaps in the laminate panelling in which dirt had collected. Floor edging was noticeably dusty. The back of the ultrasound machine was visibly dirty. The clinic did not have appropriate cleaning equipment to prevent cross contamination. For example, they did not have the range of mop buckets and heads required for dealing with cleaning needs.

We saw several packs of disinfectant wipes were 2 years out of date. We informed staff and they discarded the packs immediately.

Clinicians used sterile ultrasound gel for transvaginal (TV) scans. They kept large 5 litre tubs of the gel in the storeroom and refilled individual gel bottles from there. Governmental guidance states gel should not be decanted from larger container into other bottles. Further, once opened, gel bottles should be dated and disposed of after one month.

There was no clear process for monitoring the effectiveness of infection and prevention process. We did not see evidence the service conducted regular infection prevention and control (IPC) audits.

Administrative staff cleaned children’s toys in the waiting room after each use. However, this was not recorded.

The service did not have any risk assessments or protocols relating to the identification and management of infectious diseases.

The clinic had wipeable furnishings in the waiting room and clinic areas.

Staff adhered to infection control principles including hand washing. Staff had access to personal protective equipment (PPE) including gloves and aprons, in a range of sizes in accordance with Health and Safety Executive requirements. The sonographer carried out regular handwashing before and after patient contact. PPE was available for patients in the reception, for example facial masks and hand sanitiser. The patient couch was covered with paper towel, which was changed between patients the couch wiped down after each use.

The service used an external waste collection company to collect and destroy clinical and nonclinical waste.

The clinic had access to biohazard and urine/vomit spill kits, which were in date.

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