Rainbow Baby Scans

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

This means we looked for evidence that there was a strong learning culture. That people were protected from abuse and avoidable harm. We checked systems and pathways, the environment, maintenance and equipment. We made sure staff had the knowledge and skills to adequately assess people and that the service understood how to maintain adequate infection control measures.

This is the first assessment for this service. This key question has been rated Good.

Good: This meant people were safe and protected from avoidable harm. The was a strong learning culture services were planned and organised to meet the needs of the local population, Staff protected people from avoidable harm and people were supported to make choices that balanced risk.

However, we found a breach in regulation relating to safe care and treatment.

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.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.

The service had a proactive safety culture. Staff knew what incidents to report and how to report them. The service followed the significant events and near miss policy which described the reporting process, and staff could access incident reporting forms electronically if required.

The service had no recorded serious incidents in the last 12 months. However, staff were proactive and could describe where and how to report an incident and how to escalate these if needed. Staff described the types of reportable incidents. However, there were no incidents logged within the reporting period.

The manager told us they would share learning from any incidents with staff to support learning and improvement or to update third party organisations if and when required.

Women were able to provide feedback, and the manager gave an example of how they responded to feedback. For example, women fed back that if they were unable to see the baby’s face during a 4D scan they felt disappointed. Because of this the manager provided half hour appointments and if the baby was not clearly visible women were offered a follow up scan at half the cost.

Staff understood duty of candour, which is the duty to be open and honest if there is a notifiable safety incident, and to apologise. However, there were no serious incidents which required the duty of candour to be used. Staff gave examples of how and when to apply duty of candour. For example, if there was a significant error during the scanning process or if women raised a complaint that highlighted failures in care.

The evidence showed some shortfalls. Staff did not always manage or monitor people’s safety. However, the service did establish and maintain safe care systems and ensured the safe transition of women into NHS services.

Staff did not always manage women’s referrals safely and lacked some awareness of the of the risks to women and their unborn baby. Women had easy access to the online booking system, they entered basic details and completed a digital form after payment. However, there was no evidence of an effective pre‑appointment risk assessment prior to attendance. Staff told us they checked the risk assessment on arrival which did not ensure all risks were identified at the earliest stage of the pathway in line with NICE Antenatal Care (2024) guidelines. NICE recommends that the required information should include factors that may affect pregnancy. Following the assessment, the manager updated the form to include limited additional questions. However, the health questionnaire remained incomplete because it failed to capture key risks that are known to affect fetal growth. These comorbidities include but are not limited to; thyroid disease, diabetes, epilepsy, depression and high blood pressure.

Staff planned and organised care with women, their partners and third-party providers to ensure women had continuity of care. Women could choose their appointment times and make additional requests like extra family members or additional privacy needs due to cultural norms.

The manager/sonographer had a strong awareness of key pregnancy risks to the fetus during the scanning procedure. Staff knew how to make a third-party referral to NHS organisations. They involved all the necessary healthcare services to provide women continuity of safe care. For example, they had established links with the local NHS trusts and GP services. When the sonographer identified deviations from normal, like an ectopic pregnancy, or fetal cardiac anomaly, they liaised with NHS teams and made sure they provided a follow up call to women to check on their wellbeing.

Staff understood the views of women and their partners. If the sonographer had problems finding the fetal heart or the fetus, they discussed options and risk with women and offered them the opportunity to have a transvaginal scan for free.

The evidence showed a good standard. Staff understood how to protect people’s rights to live in safety free from bullying, harassment, abuse or avoidable harm and neglect.

Staff received safeguarding training appropriate for their role and understood how to protect people from abuse or neglect.. The sonographer was trained to level 3 safeguarding which complied with the national intercollegiate ‘Safeguarding children and young people and children and young people in care’ (2025) document. Staff knew how to make a safeguarding referral but have not needed to complete a safeguarding referral in the last year.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff followed safe procedures for children visiting the service and made sure that other children were with an appropriate adult whilst the scan was being completed.

Staff gave examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act (2010). Staff had access to a safeguarding standard operating procedure which listed the contact details of the local authority and local police. Although, the service had not needed to make any safeguarding referrals during the reporting period May 2025 to June 2026.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff informed people about risks related to pregnancy scan screening and how to keep themselves safe. For example, women who wanted to access the service before their last monthly period date were advised to wait because the scan would not find an embryo if it was too early in the pregnancy. Also, staff explained the risk of ectopic pregnancy and a patient leaflet was provided on what to look for and how to contact the early pregnancy unit.

Staff involved women and families to manage risk when they arrived for their appointment. Risk assessments prior to the scan were person centred and the sonographer explained the findings to the woman. In cases where congenital abnormalities or growth delays were identified, the sonographer made sure they explained their findings of the scan. They gained consent for making additional referrals such as the NHS early pregnancy units, or a national paediatric cardiac anomaly hospital.

Women were able to communicate their needs, emotions or distress and staff managed this is a positive way that protected their rights and dignity and maximised learning for the future. For example, staff offered women who had suffered a failed pregnancy a free pregnancy loss counselling session with a counsellor qualified to understand pregnancy loss and bereavement.

Staff found effective ways to communicate with patients with communication difficulties. Staff accessed a digital language application for non-English speaking women and families.

The evidence showed some shortfalls. The service did not always make sure that the facilities, or equipment supported the delivery of safe care. Staff did not complete routine equipment maintenance checks on all equipment. However, the environment was clean and easy to access.

Staff did not always check equipment in line with national guidance. The manager had not arranged up-to-date portable appliance testing (PAT) for service equipment. The previous certificate had expired in 2025. Although equipment, including the scanning machine, photocopier and computers, appeared to be in good working order, there was no evidence that PAT testing was current. We raised this with the manager during the assessment. They arranged PAT testing, and after the assessment provided evidence that it had been completed.

Staff had not ensured that the scan ‘sonograph’ machines routine calibration had been arranged or completed. Records showed that the sonograph calibration certificate had expired in July 2025. We raised this with staff who immediately arranged for a remote calibration. After the inspection staff provided evidence that an engineer had also completed an onsite calibration of the sonograph.

Staff did not keep records of routine equipment checks, and records confirmed the scanning machine had not been serviced for 2 years, the last service was July 2024. We raised this with staff who immediately booked a remote service. Evidence submitted following our onsite visit showed that a remote test had been completed and that a request for a service had been escalated. The manager later confirmed that the engineers attended on site on the 24 June 2026 to complete an annual maintenance check.

The premises were secure and safe. Staff made sure that there was a clear ‘Please knock’ sign on the sonographer’s door which opened into the waiting area to protect women’s safety.

There were effective arrangements to monitor the safety and upkeep of the premises. A certified fire safety company had completed its annual safety check in June 2026, and this was due to expire during the assessment process. The registered manager booked a follow up during the assessment process. An external company completed weekly fire alarm testing and calibrated the fire alarm biannually.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff who received effective support, guidance and development. Staff worked together well to provide safe care that met people’s individual needs.

Staffing levels and skills mix were suitable for the size of the service. The service recruited one full-time sonographer who was also the registered manager and one receptionist. The service provided a support sonographer to cover leave who had the knowledge and skills and was trained in the NHS. The service did not have any vacancies nor used agency staff to cover the service.

There was an effective recruitment process. The service had safe employment requirements and the manager ensured they completed the appropriate disclosure and baring service (DBS) and identity checks. Staff provided copies of their DBS status and their qualification certificates.

There were safe levels of staff with the right skills. There was minimal staff turnover during the reporting period because until recently the registered manager had worked alone supported by their partner. Staff sickness was minimal, staff told us they rarely went sick but in the event of sickness they would inform the manager who would act to cover staff.

Staff received training appropriate to their role. Training was provided by a national health training online service which met the continuing professional development standard. Training records were stored online and accessed with secure log in information. Data showed that the manager/sonographer had completed appropriate courses, including basic life support, first aid, safeguarding, information governance, moving and handling, infection prevention and control, hand hygiene and fire safety. Training was suitable for the needs of pregnant women.

The recently employed receptionist had completed basic information governance training and at the time of the assessment was in the process of completing their safeguarding training.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. However, the service appeared visibly clean.

The service did not have an effective approach to assessing and managing the risk of infection in line with national guidelines. For example, the digital booking form did not ask women about any recent exposure to infectious diseases or if they had been abroad in the last 2 weeks. Although it did contain a statement about Covid 19. This meant that staff had not considered contagions that could negatively affect the unborn fetus.

Staff were not clear about their roles and responsibilities around infection prevention and control. Staff did not consistently record cleaning activities and cleaning records were not routinely updated. For example, staff had not maintained a toilet cleaning checklist and touch point check lists had not been updated. We raised this with the manager who was unable to clarify who was responsible for cleaning.

Following the inspection, we advised the manager they did not have a cleaning schedule, and governance records were not accurate. Our concerns included an inaccurate review date on the infection prevention and control policy, which stated it had been implemented in September 2023, but incorrectly showed an expiry date of 2025 rather than September 2026.

However, staff understood most aspects of how to reduce the risk of infection. For example, the waiting area was visibly clean free from clutter and hand sanitising gel was available for people using the service. The scanning room equipment appeared visibly clean. The sonographer had all the necessary cleaning wipes and vaginal probe decontamination foam and single use sheaths.

The service did not store or prescribe medications as this practice did not form part of their remit.