Hey Baby 4D Middlesbrough

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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 inspection for this service. This key question has been rated good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-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 evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a vision and values. All staff were familiar with and understood the vision and values. Staff worked consistently to achieve provision of ‘an exceptional service to a diverse community with safety and compassion at the heart of everything’ they did.

Hey Baby 4D Middlesbrough operated as a franchise. The registered manager maintained close links with other franchise locations across the country to ensure the local vision was aligned to the wider Hey Baby 4D vision.

Staff told us they felt part of the team and actively contributed to the future vision. Staff demonstrated commitment and compassion towards supporting the longer-term development of the service.

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.

Leaders had the skills, knowledge and experience to perform their roles. The service had been set up based on personal experiences and a good understanding of the service provided.

Leaders were able to clearly articulate the service and made sure that all staff had relevant experience placing emphasis on the desire for all staff to have had previous experience in health care roles.

Leaders placed value in developing opportunities for staff and created individualised development plans with staff. For example, the sonographer was working on updating an induction package for new staff.

Staff told us the registered manager was always available and approachable.

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 had a whistleblowing policy that encouraged staff to raise concerns confidentially without fear of retribution to an independent senior leader. Alternatively, staff were directed to appropriate other services for support with raising concerns. Staff told us that they all felt equally valued and comfortable to raise any concerns within the small team of four.

The registered manager was readily available to meet with people raising concerns and was passionate about ensuring there was a culture where people felt they could speak up and have their voice heard.

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

The service was made up of four staff who all championed equality and diversity. There was an equality, diversity and inclusion policy and all staff completed training that supported them to deliver care in line with the policy. This ensured people with protected characteristics as defined in the Equality Act 2010 were able to receive care without bias.

The registered manager made sure that all staff had access to appraisals regardless of role and responsibilities.

Flexible working arrangements were available, and we heard reasonable adjustments would be considered when needed although this had not been needed for any staff since opening. The registered manager was able to give examples of considerations where reasonable adjustments or flexibility may be needed, for example, referenced awareness of the need to be menopause friendly.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework for team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

We reviewed team meeting minutes and saw action points clearly identified with action owner and date to be actioned by. One to one minutes also followed a formal system for recording action points.

Staff undertook clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

There was a risk register for the service. The registered manager maintained oversight of this and staff were able to input into the management of risk, issues and performance. The team meetings included space for escalation of risk concerns.

The service had plans for emergencies, for example, breakdown of scan machine or staff sickness. The Business Continuity Policy outlined actions to take.

Policies were in place. We reviewed policies and saw they provided clarity. Not all policies had been reviewed within the one-year period from opening the service as outlined within the providers own policy. However, the registered manager explained this work was ongoing and we saw some policies had been reviewed and updated. We also saw regular discussion through one to one meeting regarding agreed actions for updating the next policy. Policy updates could be prioritised according to need, for example, The Scanning Protocol Policy had been identified as one to be reviewed and any updates made prior to a new locum sonographer starting.

Staff had access to the equipment and information technology needed to do their work.

Information governance systems included confidentiality of patient records. Staff understood safe data storage. Secure back up systems were in place. General Data protection Regulations (GDPR) had been reviewed to ensure the service was operating within them. The service was careful to ensure confidentiality when using social media for marketing purposes.

The registered manager could access data and information to support them with their management role. This included information on the performance of the service.

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

The service had close connections with local NHS early pregnancy and maternity units. The team had made connections in the local community with other relevant services, for example, a local wellbeing hub and children’s hospice. The registered manager told us the service hoped to make more and stronger links with local community providers now the service was more established.

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.

All staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery.

We saw evidence of continued learning and improvement across the service in documented team meeting and individual staff meeting minutes.

The team regularly reviewed their practice through audits and feedback to enable changes to be made. For example, the team had identified some delays and confusion for people when tracking blood samples. They researched alternative processes and identified a different laboratory to work together with to ensure a much smoother and timelier outcome for people.