Leeds Screening Centre

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

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.

At our last inspection, we rated this key question as requires improvement. At this assessment, the rating remained as requires improvement. 

Governance and oversight arrangements were not consistently effective. Leaders could not always demonstrate effective oversight of recruitment, competency, safeguarding, referral management and workforce governance. These weaknesses limited assurance that risks were consistently identified, monitored and mitigated and resulted in a breach of Regulation 17 (Good Governance).

Despite the governance shortfalls identified, staff described the service as supportive and well managed, with leaders who were visible, approachable and committed to providing patient-centred care.

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.

The service did not have a clearly defined vision, strategy or measurable objectives to support future development, improvement and organisational oversight. However, the service demonstrated a commitment to patient-centred care.

The service had evolved from providing Down's syndrome screening to offering a wider range of Non-Invasive Prenatal Testing (NIPT), prenatal screening and diagnostic ultrasound services. It had relocated to larger premises and was seeking to expand its ultrasound-related services. Staff described a focus on increasing private patient activity and expanding access to services not routinely available through the NHS.

The registered manager confirmed there were no formal succession planning arrangements in place. Although the service was seeking to recruit additional sonographers, leaders could not demonstrate how critical skills, organisational knowledge and service responsibilities would be sustained if key staff left the organisation.

The service had developed a vision and strategy document which described its services and patient-centred approach. However, the document did not clearly set out strategic priorities, measurable objectives or success measures to support future service development and improvement. As a result, leaders could not fully demonstrate how long-term priorities would be planned, monitored and reviewed.

Despite these concerns, staff demonstrated a shared commitment to delivering compassionate and patient-centred care.

Leaders did not always demonstrate effective oversight of workforce governance arrangements. 

Although leaders had extensive experience within the service, governance processes did not ensure recruitment, appraisal, competency assessment and role accountability were consistently implemented.

The service could not demonstrate that staff performance and development had been formally reviewed through an appraisal process. Records showed appraisals had not been completed for four years. As a result, leaders could not demonstrate how staff performance, development needs and career progression opportunities were routinely identified, reviewed and supported.

Staff were undertaking responsibilities that were not reflected within their job descriptions, and roles and responsibilities were not always clearly defined. We identified variations in safeguarding knowledge and reporting arrangements, reducing assurance that leadership communication and oversight were consistently effective.

Although workforce policies were in place, leaders had not consistently ensured recruitment, appraisal, training and competency processes were fully embedded and effectively monitored. This reduced assurance that workforce governance arrangements were operating effectively and that staff were consistently supported to undertake their roles safely and effectively.

Despite these concerns, the registered manager had led the service since 2003 and retained overall responsibility for regulatory compliance. They demonstrated a commitment to delivering a positive patient experience and responded promptly to concerns identified during the onsite inspection, taking immediate action where required.

Staff described the leaders as accessible, responsive and supportive. They told us they felt able to raise concerns, seek advice and ask for support when required.

The service fostered a positive culture where patients and staff felt able to speak up and be heard.

A whistleblowing procedure was included within the employee handbook and encouraged staff to raise concerns relating to wrongdoing, legal non-compliance, health and safety risks and other matters in the public interest. The procedure stated that staff raising concerns would be protected from bullying, harassment or other detrimental treatment.

Although the whistleblowing guidance was contained within an employee handbook last reviewed in 2018 and did not reference more recent speaking-up arrangements or alternative reporting routes, staff demonstrated an understanding of how concerns could be raised and expressed confidence in doing so.

Following the onsite inspection, the service submitted a staff feedback and concerns form. Whilst this demonstrated recognition of the need for a more formal mechanism for staff to raise concerns and share feedback, this had not been embedded into practice at the time. 

The service encouraged patients and staff to share feedback, raise concerns and contribute ideas for improvement. Staff told us they felt comfortable speaking up and were confident concerns would be taken seriously and addressed appropriately.

The service promoted an inclusive and fair workplace culture and supported equality, diversity and inclusion within the workforce.

The Employee Handbook included an Equal Opportunities Policy and Personal Harassment Policy. These policies described the service's commitment to preventing discrimination, promoting equal opportunities and supporting staff from different religious, cultural and personal backgrounds. Guidance stated that reasonable adjustments and cultural or religious dress requirements would be accommodated where possible.

Staff had completed equality and diversity training and were able to describe inclusive working practices and non-discriminatory care.

The service made reasonable adjustments to support staff in carrying out their roles, including providing saddle seats and adjustable desks to promote comfort and wellbeing in the workplace.

Leaders demonstrated flexibility in supporting individual staff needs by accommodating preferred working arrangements and developing rotas around personal circumstances where possible.

Staff described an inclusive working environment where they felt respected, treated fairly and supported. They did not report experiencing discrimination, bullying or exclusion and described positive working relationships across the service.

Governance arrangements were not effective in providing clear accountability, oversight and assurance regarding the quality and safety of the service. Systems and processes did not consistently identify, assess, monitor or mitigate risks relating to safeguarding, recruitment, workforce competence, staff responsibilities, referral and triage arrangements, policy management, environmental safety and emergency preparedness.

The service could not provide assurance that safeguarding concerns would be recognised, escalated and overseen appropriately. There was no effective oversight of safeguarding training, competence and referral processes. Safeguarding leadership arrangements were unclear, training records were incomplete, staff knowledge was inconsistent and the service could not demonstrate access to an appropriately trained Level 3 safeguarding lead. These concerns represented a continued breach of Regulation 13 (Safeguarding).

Governance systems did not consistently identify, monitor and mitigate risks relating to recruitment, workforce competence, safeguarding oversight, referral pathways and policy management, reducing assurance that leaders had effective oversight of service quality and safety. 

Policies and processes were not consistently implemented or effectively monitored. Recruitment records contained gaps in required information, and referral and triage arrangements were not subject to effective oversight. Governance arrangements did not ensure staff responsibilities were clearly defined or supported by appropriate training, competency assessment, safeguarding and escalation arrangements.

Staff roles and responsibilities were not always clearly defined. For example, governance documentation referred to both "screening coordinator" and "patient coordinator" roles, creating ambiguity regarding role titles and responsibilities. In addition, some responsibilities undertaken by staff, including chaperoning and communicating Non-Invasive Prenatal Testing (NIPT) results, were not reflected within job descriptions.

These findings did not provide assurance that leaders had effective oversight of service quality, safety and staff competence.

Governance systems did not ensure policies were current, accessible, relevant or reflective of the services provided. Governance documents were not consistently maintained, reviewed or version controlled, and many were generic and not appropriately adapted for an independent diagnostic ultrasound service. For example:

• The Infection Prevention and Control policy contained references to procedures not undertaken by the service and included Scottish guidance not applicable to services operating in England. The policy also referenced appendices and supporting documents that were not available.
• Cross-referencing and version control arrangements were not always effective, with inconsistencies identified between policies.
• The accident, near-miss and first aid policy included risks and activities not relevant to the service whilst omitting some service-specific operational arrangements.
• The blood sample-taking protocol did not describe the NIPT transport process or sample verification arrangements.
• The Patient Safety Incident Response Framework policy contained NHS-specific governance arrangements that did not apply to the independent sector.
• The consent policy contained references to children and young patients despite the service not treating these patient groups.
• The complaints policy had not been reviewed since January 2016, continued to reference the Data Protection Act 1998 and did not signpost patients to independent external escalation routes.

Staff were not always able to access key operational information held on the service's electronic systems and were reliant on managers to locate information. Following the onsite inspection, the registered manager confirmed that all staff now had access.

The employee handbook had not been fully updated and continued to reference superseded legislation, including the Data Protection Act 1998.

Systems for monitoring safety and environmental risks were not consistently effective. Although the service completed weekly checking processes and quarterly cleaning audits, these failed to identify multiple significant concerns. 

Although concerns relating to emergency preparedness had been identified at the previous inspection, sufficient action had not been taken to ensure emergency equipment remained safe, maintained and ready for use. This reduced assurance that leaders had effective oversight of risks and that governance systems were operating effectively to identify and address concerns.

These concerns contributed to a breach of Regulation 17 (Good Governance).

Despite these concerns, governance records showed that issues identified through oversight processes were discussed and acted upon. For example, concerns regarding communication of appointment cancellations by an external referral partner were identified, escalated and reviewed through governance meetings, resulting in revised communication arrangements and improved oversight of patients who did not attend appointments.

The service had arrangements in place for information governance, risk management and emergency planning. A risk register was maintained and business continuity arrangements covered events such as information technology failures, utility disruption, fuel shortages and fire. Secure electronic systems were used to manage patient information and maintain confidentiality.

Staff understood the importance of working in partnership with other healthcare services to promote continuity of care and positive patient outcomes.

The service worked in partnership with NHS commissioners and local healthcare services. It delivered diagnostic ultrasound services under contract with a local NHS Trust, enabling patients to access services through established NHS referral pathways.

The service supported local healthcare by providing ultrasound clinics within GP practices and undertaking scans on behalf of the NHS Trust when demand exceeded local capacity. Referrals were received through recognised NHS referral systems, helping to ensure timely access to diagnostic services.

Staff described positive working relationships with local Early Pregnancy Assessment Units (EPAUs) and other NHS services across the region. This supported timely escalation, access to specialist advice and continuity of care for patients requiring further assessment, treatment or follow-up.

The service had established arrangements with external providers to support care delivery, including a contract with a national courier service for the transportation of NIPT blood samples.

Scan reports could be shared with other healthcare services, with patient consent, to support continuity of care and informed clinical decision-making. Staff understood referral pathways and escalation processes and described collaborating with partner organisations when patients required additional assessment or onward care.

Whilst the service demonstrated some commitment to learning and improvement, governance arrangements had not consistently ensured that learning was embedded and sustained over time.

At the previous inspection, the service was required to make improvements in relation to infection prevention and control and emergency preparedness. Although the service informed us that action had been taken, we identified recurring concerns during this onsite inspection, including environmental cleanliness issues and deficiencies in emergency equipment oversight. This did not provide assurance that improvements had been consistently sustained or that monitoring processes were effective in identifying and addressing emerging risks.

The service completed audit and monitoring activities; however, these had not identified some of the concerns found during the onsite inspection, including environmental cleanliness concerns. This reduced assurance that leaders had effective oversight of the impact of improvement activity and associated risks.

Despite these concerns, leaders responded positively to issues identified and took action to address concerns raised.

The registered manager told us they had previously supported the training and development of National Health Service (NHS) staff and welcomed healthcare professionals to observe scans within the service to support learning and professional development.

The service supported learning through audit activity, case discussions and engagement with professional networks. Learning from clinical practice, audit findings and professional updates was discussed within governance and audit meetings to support reflection and continuous improvement.