Baby Moments

On this page

• 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 patients who used the service. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated and person-centred.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

The service was in breach of regulation in relation to governance as some areas of governance were not sufficiently robust to ensure effective oversight of the service. The service was inconsistent regarding environmental and clinical risk assessments. The service had a risk log for corporate and clinical risks. However, this did not contain documentation of action plans, next steps, and dates of completion.

However, the service had a shared vision and culture, and staff knew about this. It was run by compassionate and kind leaders who created and open and honest working culture. Staff felt safe to speak up.

The service had a shared vision and culture, and staff knew about this. It was run by compassionate and kind leaders who created and open and honest working culture. Staff felt safe to speak up.

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.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency and understanding challenges and the needs of people and their communities.

The provider had a vision and values document in place, underpinned by a 5-year strategy. The service aimed to provide safe, compassionate, confidential and accessible ultrasound care, ensuring every patient felt respected, listened to, and supported throughout their obstetric and gynaecology journey. The 5-year strategy focused on patient-centred care, clinical quality and safety, workforce and culture, and sustainability and growth.

We found an open and honest culture, where the team clearly worked well together. As the team was small, they all knew each other well and worked towards the same goals of making this service successful.

The service did not display their vision and values in the clinic but planned to do so in the future. Staff induction did not include orientation on vision, values, and expected behaviours. We did not see evidence the vision and values were on the agenda for regular team meetings. There was no evidence the service monitored how they delivered against their plan.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The lead clinician, who was also the registered manager, had completed a variety of training and was competent to fulfil their role. In addition to working at Baby Moments, they also worked in an NHS ultrasound clinic. The sonographer received all their professional development and mandatory training in the NHS trust. In addition, they had appraisals in both locations.

The lead clinician was approachable and friendly and the atmosphere between staff of different grades was relaxed and equal.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service did not have a freedom to speak up guardian, which was proportionate for its size. Staff told us they could raise issues in-house without fear of reprisal. They advised us they felt listened to by leaders and confident, if they raised a concern, it would be taken seriously. However, the provider did not have any formal procedure for staff speaking up and whistleblowing.

We scored the service as 3. The evidence showed a good standard. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff could work flexibly to account for personal circumstances such as caring responsibilities and health issues. Both clinical and non-clinical staff had cover arrangements in place.

The provider had an equality, diversity and inclusion policy in place and staff received training in this.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

While reference was made to 3 different meetings, the service held only one meeting where discussions took place. From the review of the minutes the team covered topics such as research, staff training, lone working, appraisals, complaints and compliments, cleaning rota, and patient feedback. The risk policy stated there was a quarterly governance meeting, but this is not what the service did.

The service had an audit schedule, including environmental, staff-related, patient-related, and clinical audits. The schedule outlined how often audit activities were reviewed and when and where they would be discussed. For example, the staff wellbeing audit was meant to be covered at the monthly team meeting. In the 3 sets of minutes we reviewed, there was no mention of staff wellbeing. This was not in line with what they did at the time of the
assessment.

The service did not have a policy relating to the General Data Protection Regulation (GDPR) 2018. Staff were unclear how long the service should keep personal data. They advised us they “kept everything”. We found numerous boxes in a lockable cupboard containing years of patients’ consent forms.

The policies did not always reflect the service provided by the clinic.

The service was inconsistent regarding environmental and clinical risk assessments. For example, we saw a tub of disinfectant tablets on the worktop in the storeroom but no risk assessment to identify potential hazards. The service employed an external health and safety advisor who ensured a risk schedule was in place. This schedule outlined risks, mitigations and actions. It did not have dates of when actions should be completed. The service held a risk log which covered corporate and clinical risks. However, this did not contain documentation of action plans, next steps, and dates of completion.

The ultrasound machine and the computer at reception were password protected and therefore secure. We witnessed staff logging out of the computer when they left their workstation. Staff recorded patient visits and scans electronically on a safe software platform.

The provider had a business continuity plan in place, covering issues such as staffing, loss of computer system, major incident, and loss of access to scan reports. The plan included responsibilities, impact, likelihood, and recovery timeframe and was comprehensive and up to date.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The service had established good working relationships with partners in the NHS, which allowed for seamless referrals and information sharing. The sonographer printed off reports for patients to take with them to their appointment. They also sent emails to the relevant unit with the scan images.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff we spoke with were aware of future business plans and were actively involved in the development process. Discussions around developing services were noted in team meeting minutes.

The service had worked to improve the digital patient experience. This included an online booking system with real-time availability, automated reminders, and secure online payments. This had shown to reduce missed appointments, improve patient convenience, and reduce administrative workload.

The service linked with a local university to find pregnant women to participate in a research study. They displayed leaflets about the study in their waiting area. The study was led by the sonographer who covered for the service’s sonographer in their absence.