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Inspection Summary


Overall summary & rating

Good

Updated 16 December 2019

Miracle Inside UK Ltd is operated by Miracle Inside UK Ltd.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 29 March 2019. Our inspection was unannounced (staff did not know we were coming).

To get to the heart of service users’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We rated this service as Good overall and found the following areas of good practice:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care.

  • Managers appraised staff’s work performance annually and checked to make sure staff had the right qualifications and professional registration for their roles.

  • The environment was appropriate and met the needs of the range of people who accessed the service.

  • The service provided care and treatment based on national guidance and could evidence its effectiveness.

  • Women could access services and appointments in a way and at a time that suited them.

  • The service treated concerns and complaints seriously. The registered manager completed comprehensive investigations and shared lessons learnt with all staff.

  • Staff were caring, compassionate, and kind, and engaged well with women and their families.

  • The service took account of service users’ individual needs.

  • Managers promoted a positive culture that supported and valued staff. Staff reported that their team worked well together, and they trusted and respected each other.

However, we also found the following areas the service provider needs to improve:

  • The service did not control all infection risks effectively.

  • Managers did not provide evidence that they monitored the effectiveness of care and treatment and used the findings to make improvements.

  • Managers did not provide evidence that they evaluated images to ensure they were of good quality.

  • The service did not collect, analyse, manage, and use information to support all its activities.

  • The service had not completed a risk register and did not evidence the management of risks, for example, looking after children during procedures.

  • Some policies and procedures were not dated and were not specific to this organisation.

  • Following this inspection, we told the provider that it should make some improvements, even though no regulation had been breached, to help the service improve. Details are at the end of the report.

    Ann Ford

    Deputy Chief Inspector of Hospitals (North)

Inspection areas

Safe

Good

Updated 16 December 2019

We rated safe as Good because:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.

  • Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • We observed well-presented staff who kept the equipment and premises clean.

  • Staff kept clear records and completed and updated risk assessments for each woman through individual follow-up referral forms.

  • The service had enough staff with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • Staff kept detailed records of women’s appointments and referrals to NHS services and completed scan consent documents.

  • The service had appropriate processes for staff to raise concerns and report incidents.

  • Staff understood their roles and responsibilities to raise concerns and record safety incidents.

However:

  • The service did not control all infection risks effectively.

Effective

Updated 16 December 2019

We do not rate effective for this type of service. We found the following areas of good practice:

  • The service provided care and treatment based on national guidance, and there was evidence of its effectiveness.
  • Staff ensured women were comfortable, relaxed, and reassured during ultrasound scans.
  • The service made sure staff were competent for their roles.
  • Managers appraised staff’s work performance, and there were processes to assess sonographers’ competencies and suitability for their roles.
  • Staff worked together as a team to benefit women and their families.
  • Staff provided women with information regarding the scan findings and health promotion information regarding their pregnancies.
  • Staff understood how and when to assess whether a woman had the capacity to make decisions about their care.

However:

  • Managers did not provide evidence that they monitored the effectiveness of care and treatment and used the findings to make improvements.
  • Managers did not provide evidence that they evaluated images to ensure they were of good quality.

Caring

Good

Updated 16 December 2019

We rated caring as Good because:

  • Staff cared for women and their families with compassion. Feedback from women and their partners confirmed that staff treated them well and with kindness.

  • Staff provided emotional support to service users to minimise stress.

  • Staff involved women and those close to them in decisions about their care and treatment.

Responsive

Good

Updated 16 December 2019

We rated responsive as Good because:

  • The service planned and provided services in a way that met the range of needs of people accessing the clinic.

  • Women accessed the service and appointments in a way and at a time that suited them. There were no waiting times for appointments, and women self-referred to the service.

  • The service had a complaints policy and treated concerns and complaints seriously. The registered manager investigated complaints and shared outcomes with all staff.

Well-led

Good

Updated 16 December 2019

We rated well-led as Good because:

  • Managers had the right skills and abilities to run a service providing high-quality sustainable care.

  • The service had a vision for what it wanted to achieve and plans to turn it into action.

  • Managers across the service promoted a positive culture that supported and valued staff.

  • The service engaged well with women, their partners, and local organisations to plan and manage appropriate services.

  • The service was committed to improving, by learning from when things went well or wrong, and to promoting training.

However:

  • The service did not have good systems to identify risks or to plan to eliminate or reduce them.

  • The service had not completed a risk register and did not evidence any management of risks.

  • The service did not provide evidence that it had collected, analysed, managed, and used information well to support all its activities.

  • Some policies and procedures were not dated and were not specific to this organisation.

Checks on specific services

Diagnostic imaging

Good

Updated 16 December 2019

This is a diagnostic imaging service run by Miracle Inside UK Limited. The service is based in Leeds, West Yorkshire.

We rated this service as good because it was safe, caring, responsive, and well-led.  We do not rate effective for this type of service...