My baby and i scan Ltd

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 people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated as Inadequate.

This meant people were not safe and were at risk of avoidable harm.

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 significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not have systems in place to raise concerns about safety and did not investigate or report safety events. There was no process to capture lessons learnt to continually identify and embed good practice.

Staff could not demonstrate or give examples of when the duty of candour would apply. There were no audit tools available to capture or record adverse events, and no incident log was available on the day of inspection. A lack of recorded incidents meant there was an inability to review and, when appropriate, learn from these incidents. The registered manager could not provide information about the processes they would use and how this would be recorded and actioned

The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The services’ referral and appointment processes could not ensure that all essential information about the patient was received to determine if the patient’s needs could safely be met. On the day of inspection, staff could not demonstrate that they involved all the necessary healthcare services to ensure patients had continuity of safe care. They stated, and we saw on the consent form, an option for a patient to refer themselves to additional services if required, such as an early pregnancy assessment unit (EPAU). When registration was interviewing, the registered manager, the information given was contradictory to this, and they stated the service would not scan if consent to refer was not given for concerns. However, best practice would be for the service representative to contact the EPAU directly and provide the findings of the scan and make an appointment for the patient. A failure to do this may delay review and timely actions to ensure patient safety.

Staff stated that concerns about scans, such as an unviable pregnancy, were documented on the consent form, but we did not see clear evidence of this. Therefore, patient records were not fully completed. Although contact details for local EPAUs were on display, policies and processes were not in place to refer clients to relevant services if abnormalities were identified. There were no clear processes to document the escalation of concern for patients receiving scans, aside from a note on an ultrasound report. We observed a woman being scanned outside of the provider policy, which stated there should be 2 weeks between scans unless there is a documented discussion as to why there has been a deviation. This discussion had not been documented. However, following the inspection, evidence was given of a newly designed blank form to record when a patient was referred to services.

The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. They did not share concerns quickly and appropriately.

We saw in training files that staff did not have the appropriate level of safeguarding training for a registered healthcare professional. On the day of inspection, we viewed a staff member’s training record with an online training group. We found that level 2 safeguarding training had been started in June 2024, but was incomplete, and level 3 training had not been started. However, since the inspection, the appropriate level of safeguarding training is now in place.

There was no evidence that the service worked with other organisations, such as the local safeguarding team, to discuss any concerns or make referrals. During the inspection, the registered manager, when prompted, was able to share that they would contact other organisations for advice, such as the local authority safeguarding team. However, no safeguarding referrals had been made.

Although the service’s statement of purpose stated they would accept clients 16-17 years of age, staff told us the service did not accept clients under the age of 18. The registered manager showed a lack of understanding of Gillick competency for 16-17 year olds. This was previously fed back as an area for improvement during their registration as a manager. There were no clear processes to demonstrate and review the escalation of concern for women receiving scans, aside from a note on an ultrasound report.

All staff, including the registered manager, did not have an appropriate Disclosure and Barring Service (DBS) check in place at the time of inspection. We viewed an online DBS which was registered to a previous employer, and certificates which were incorrectly registered to another employer. No previous employment references were available on the day of inspection. Following inspection, evidence was provided of new compliant DBS certificates.

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe and supportive.

During our inspection, we saw 1 scan and observed that this was undertaken outside of the provider’s policy, as it had been less than 2 weeks since their last scan. The reason was put down to patient anxiety, and that the scan offered reassurance. No risks were discussed with the patient whom we observed, and the patient was not involved in managing the risk themselves. Instead, we were told by the sonographer that a conversation had happened with the patient’s husband, who had identified the patient’s anxiety around this pregnancy. This was given as a reason to scan more frequently, with no record kept of the deviation from their policy or any conversations had with the patient. Following the inspection, a new exception to the scan interval form had been introduced to document these conversations. The service did not have a referral pathway for women experiencing acute anxiety or mental health crises during pregnancy. On the day of inspection, we observed there were reasons to consider support and signposting, but red flag indicators were not considered for clients with reheated attendance.

During our inspection, we saw 3 patient consent forms where concerns had been identified during the scan. We saw that whilst the sonography was kind and compassionate on our observed scan, they did not correctly record and identify actions the patient should undertake to seek further and timely medical review. This meant there may be a delay in the patient’s timely care and treatment.

The consent form was translated into 3 languages other than English. When asked how staff otherwise communicated with patients so that they understood their care and treatment, no alternative was offered. However, following the inspection, Google Translate has now been installed on the business phone.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The location did not have relevant environmental risk assessments in place to ensure staff and client safety. We found a lack of health and safety, fire checks and procedures in place, which may put people at risk of harm. Fire drills had never been undertaken. There was no testing programme in place for fire and smoke detectors at the time of inspection. We observed fire and injury risks in the reception area and clinic room. Loose leads from freestanding portable heaters were a trip hazard, and there were no guards to protect people. The registered manager could not provide a completed risk assessment for the portable heaters when requested during and after the inspection. There were in-date portable appliance testing (PAT) stickers on some appliances, but not others. We could not be assured that the PAT testing had been done, as there was no overview log. After the inspection, a log of compliant items was provided.

Control of Substances Hazardous to Health did not always follow guidance, as there were no completed data sheets for all products used. Emergency lighting maintenance checks were unavailable.

We observed there were appropriate servicing, maintenance and checks of the ultrasound machine.

The evidence showed significant shortfalls. The service did not make sure there were enough staff with relevant mandatory training. The Sonographer was the designated first aider yet did not have a suitable qualification to perform that role safely. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The staff member undertaking scans was a Health and Care Professions Council Registered Radiographer, with additional training and qualifications in ultrasound. However, staff received online mandatory training to the Care Certificate level, an entry level for unqualified health care staff. The registered manager was unaware that this was not appropriate for their role. There was no personal development training identified by the registered manager for staff, and there were no appraisals or records of supervision.

There were no employment checks in any staff files. There were no documented staff induction processes, and no audit of staff files. On the day of inspection, a staff file overview sheet was observed, but it was not reflective of what was contained within staff files. The registered manager could not provide us with previous employment references when asked. There were no documented appraisals or records of supervision. Staff told us they were undertaking courses for continuous professional development, but these were not directly related to the service.

Staff stated that concerns about scans were documented on the consent form, but we did not see clear evidence of this. Therefore, patient records were not fully completed.

Following the inspection, the provider sent evidence of completion of manual handling training and safeguarding, but not all other mandatory training.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The registered manager could not provide any infection prevention and control audits, but planned on introducing them. We observed that staff were bare below the elbow, but didn’t observe any hand hygiene before scanning a patient. However, there was no handwashing sink in the scan room, and we did observe the sonographer wear a pair of gloves. The handwashing sinks did not have suitable taps that met infection control Health and Safety Executive requirements. We observed equipment was cleaned after use, but this was using household wipes. The decontamination foam usually used had run out, and there was no replacement. There was no evidence of a stock management system. However, since inspection evidence of a stock control audit form has been devised but not used consistently. There was no data sheet for the decontamination foam or the wipes. There was a daily cleaning tick list for the scan room, which had been consistently completed.

There was carpet in the clinical area. This should be avoided as per Department of Health Building Note 00-10 Part A: Flooring. The carpets throughout the service appeared visibly clean, and staff told us they were cleaned weekly, but we saw no evidence of this. Chairs in the clinic were fabric covered and were not easily cleanable.

The clinical waste bin outside was in a publicly accessible area and not fully secured. This meant the public could access the contents of the clinical waste bin and the contaminated waste. On the day of inspection, the registered manager could not provide us with the service level agreement for clinical waste. Following inspection, the provider supplied us with evidence that a new bin and waste contract had been sourced.