Rainbow Baby Scans

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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

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 people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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

The manager was capable, compassionate and inclusive. They understood equality, diversity and inclusion and the importance of partnerships and working with the local community. They understood the importance of learning from improvement.

However, due to limited capacity until recently we found there was a lack of shared direction, and gaps in governance, management and sustainability.

We found 1 breach in regulation relating to good governance.

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 evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The manager did not always understand their CQC responsibilities.

The service did not have a clear vision statement. However, the manager told us their aim was to offer a holistic service that celebrated conception, pregnancy and parenthood. They offered additional services like antenatal classes and counselling.

Staff demonstrated a positive, compassionate listening culture. They promoted trust and understanding between them and the women who used the service. The recently recruited receptionist was clearly visible and empowered to contribute their ideas to the service. When women called the service, the receptionist was able to explain the services offered and the links to other services, like emotional support and antenatal classes. They also liaised with local NHS services and fed back to women and their famili8es.

The evidence a good standard. The manager had the skills, knowledge, experience, and credibility to lead effectively. However, the service lacked a clear vision and oversight governance.

The leader had the experience and capability to oversee the delivery of the service vision. Rainbow Baby Scan was a small independent provider registered with the CQC for the regulated activity of diagnostic and screening services. They understood what they needed to do. However, they did not have the capacity to deliver the vision or make sure that risks were well managed until the recent employment of the receptionist. The registered manager had operated the service independently for a prolonged period. This reduced management capacity and contributed to gaps in oversight, governance and monitoring arrangements.

The manager was knowledgeable about issues and the priorities of the service. They understood what was working well and what required improvement and they made plans to seek improvement. For example, they looked at complimentary pregnancy services like antenatal classes, hypnotherapy and emotional counselling to help provide a holistic antenatal service.

The manager was visible and accessible for staff, women and external providers. The were inclusive and approachable and modeled inclusive behaviours. For example, they were flexible and willing to change their working pattern to accommodate the needs of women and external providers.

However, the manager had employed a receptionist, the manager had yet to establish a clearly defined roles and responsibilities. This created uncertainty about accountability for some operational tasks and administrative functions. During the assessment, we shared our concerns about lapses in oversight with the manager. They responded positively and acted promptly to address the issues we identified. They showed a willingness to learn, improve and drive the changes needed to strengthen governance and oversight across the service.

The service was not required to have a freedom to speak up process.

The evidence showed a good standard. The service valued diversity in their workforce. The manager worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The manager had the skills to improve the culture of the organisation in the context of equality, diversity, and inclusion. They would act if there were any disparities in the experience of staff with protected equality characteristics, or those from excluded and marginalised groups.

The manager understood the need to remove bias from practices and ensure equality of opportunity and experience for the workforce. Policies were reviewed for any discrimination or bias. They would make any reasonable adjustments for staff if needed.

The manager understood when to act in order to prevent bullying and harassment at all levels. Staff worked well together their interactions were open and transparent and they worked well together.

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

There was not always effective governance, management and accountability arrangements. The service had a governance framework that included policies, standard operating procedures and processes to support safe care. However, some policies had exceeded their review dates and version control was not always clear. Although these documents remained within nationally recognised review time frames, the provider's own systems had not identified or addressed these issues in a timely way. Following feedback, the manager reviewed and updated policies and submitted evidence of these changes. This showed they were willing to learn and improve, but governance processes required strengthening to provide consistent oversight.

Quality frameworks for identifying, monitoring and managing risk were not always effective. Pre-appointment risk assessment processes were not sufficiently comprehensive and did not consistently identify relevant risks at the earliest opportunity. We also identified gaps in environmental and equipment oversight, including overdue equipment servicing, expired PAT testing and incomplete infection prevention records. Although leaders took immediate action to address these findings, the issues had not been identified through existing governance systems. However, staff understood how to report incidents and safeguarding concerns and there were established pathways to escalate abnormal scan findings to NHS services when required.

Some arrangements for patient record management had not been working effectively. There was a backlog of consent forms awaiting upload to the electronic patient record system, with some documents outstanding for up to 4 months. The registered manager had recognised the issue and recruited administrative support to address the backlog. While there was no evidence of harm to women, systems to ensure records were complete, contemporaneous and appropriately managed required improvement.

The evidence showed a good standard. The service understood the duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and learning with partners and collaborate for improvement.

The manager worked in partnership with key organisations to support the provision of care and continuity of care. These services included the local NHS trust and local GPs’ to ensure the service was aligned to evidence-based practice and women’s needs. They were taking steps to engage with the local NHS trust to act as support to alleviate long patient waiting times. In addition to this the manager recruited an independent counsellor and antenatal educator to support women during pregnancy and beyond.

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. They actively contribute to safe, effective practice and research.

The manager had a good understanding of how to make improvements happen. This was a small service focused on increasing capacity and services to improve antenatal care and drive change.

Staff were committed to improving services. There were systems and processes for learning.

The registered manager had a process that ensured learning happened when things went wrong and could give examples of good practice. For example, some women attended the service because they had not received meaningful information from NHS partners about their scans. If the registered manager found inconsistency, they fed back their concerns to local NHS services. They were in the process of seeking a service level agreement so they could provide an overflow service for the NHS.

Staff were supported to prioritise time to develop their skills. The receptionist was able to complete learning at home and was given paid time to do so.

The registered manager encouraged the receptionist to share their ideas about making improvements. The receptionist had looked at the website and local services and made several suggestions on how to attract women to the service.