Babysteps

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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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this newly registered service. This key question has been rated Inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The overall governance processes at the service were found to be inadequate. The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding, safe environments and governance. For example, the nominated individual did not have the skills, knowledge, experience and credibility to lead effectively and did not have the necessary processes in place to keep people safe.

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 1. The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There were no documented discussions around shared direction and culture; there was no strategy for the service, no vision, no evidence of care being provided in line with values, for producing high quality care.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have inclusive leaders who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The providers website stated the responsible individual was a midwife for many years; however, following a review of the National Midwifery Council register, the responsible individual had qualified as a Registered Nurse in adult services and not as a midwife.

The service did not have a leader who had the skills or knowledge to lead effectively. We found several examples that the manager did not have the knowledge and skills to provide a safe and effective service, which met the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations and were in breach of the regulations. We found breaches in Regulation 12,13,15 and 17.

There is no current evidence of continuing professional development and mandatory training. Evidence reviewed as part of the inspection showed that all mandatory training had expired and no professional development had been considered.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

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

The service had no effective governance system in place to monitor or assess the service provided. Whilst the application for the responsible individual was being assessed for registration, they were reported for conducting services as an unregistered provider. This resulted in the responsible individual being issued with enforcement action and obtaining a Warning Notice to cease trading until the time they had demonstrated they complied with regulations.

CQC registration team requested the responsible individual remove home visits from their website and standard operating procedures. We found during the assessment there was still information on every page of the website advertising this service and a portable ultrasound machine in its bag in reception. The responsible individual stated that they were not doing home visits as part of the services they offered. We were not assured that home visits were not taking place.

The responsible individual was advised, as part of their registration, they were required to hold public liability insurance; this requirement was never met, and the provider continued to operate without this essential protection.

There was no oversight or scrutiny of policies. Policies were available but were limited in detail, missing, of poor standard, or contained incorrect information.

The responsible individual told us they deleted images on the ultrasound machine after one month; we found images from August 2024 that were not deleted. No systems were in place to back up any images, and there was a lack of compliance around data storage. This meant that images were not stored in accordance with general data protection legislation, and patients did not have right of access to these images should they require them later.

The Information Commissioner’s Office (ICO) certificate of registration was out of date but still being displayed. When asked for an up-to-date certificate, we were told by the responsible individual they are no longer registered with the ICO. Picture messages on a phone and tablet, a video doorbell and CCTV within the building, all of which fall under ICO licensing.

We observed a certificate being displayed for BMUS on the entrance wall, but this certificate was out of date by 19 months.

We could not be assured that the responsible individual was operating within the scope of their registration because they did not have the systems and processes to ensure safe, effective and responsive care that meets patients needs.

We observed a blank sonographer form in the responsible individuals file, which had not been used. This form listed a procedure the sonographer was not authorised to undertake. Transvaginal scans are not advertised on the providers website and were not considered when applying for registration.

There were out of date portable appliance testing (PAT) stickers on appliances. We could not be assured that the PAT testing had been done, as there was no overview log. We saw in the diary testing had expired last year, and a date for retesting was scheduled the day before the inspection. We could not be assured this had taken place.

Necessary service contracts were not in place for the servicing of ultrasound machinery and waste disposal. The responsible individual is accountable for ensuring the appropriate service contracts are in place to protect people.

We scored the service as 1. The evidence showed significant shortfalls. The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

There were no peer review processes in place for the service to ensure the quality of the images being taken.

No evidence could be demonstrated to establish links with the early pregnancy assessment unit or patients’ GP.

We scored the service as 1. The evidence showed significant shortfalls. The service did not focus on continuous learning, innovation, and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not actively contribute to safe, effective practice and research.

The responsible individual had not undertaken any learning since their registration. This meant required learning was out of date, and there were no arrangements made to update this. When asked, they told us that they had not looked at external development and had not considered any service related development. There were no discussions recorded around research in practice or any quality improvement methods at the service.