The Baby Skan Studio

On this page

• 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 leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. The service was in breach of the legal regulation in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear documented vision or strategy. This was raised at the pervious inspection. However, the provider was able to talk to us about the plans to re-locate the business to a new location which had accessibility benefits and a larger clinic room. The mission described on the service’s website was for people, “to feel safe and at ease during your baby scan experience”. There was however no mission statement for the private men and women’s health check business which was called “Ultrasound Cornwall”.

The service was led by a registered person who had a lot of experience in the sector, however governance processes were not robust. Leaders understood the context in which they delivered care, treatment and support and provided a culture for staff which encouraged inclusion. They were visible and approachable in the service for people and staff.

Staff said the registered person was approachable and they felt they were supported.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. We spoke with staff who said they were comfortable to raise any issues with the registered manager.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture towards each other and people using the service. We spoke with staff who stated they enjoyed working for the provider and felt they received fair and equitable treatment.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always document information about risk, performance and outcomes. Information was however shared securely with people and other providers who accepted referrals from the service.

We observed there had been some improvement in governance processes since the last inspection, however there were still aspects of governance that required improvement. Governance processes help to mitigate risk and improve decision making, impact on culture and allow for accountability.

There was a lack of documentation for governance processes. For example, there was no incident log and no cleaning log.

The registered person understood the risks to the business, which included the lack of sonographers and risk to business continuity, however there was no formal risk register to document this and record actions and mitigations. There was a risk assessment policy which covered slips, trips, falls; violence; manual handling; blood spillage and electrical equipment.

At the last inspection in 2019 , appraisals were not conducted and at this inspection we were told appraisals were still not conducted. There was no formal mechanism for communicating with staff such as monthly meetings.

There was no business continuity plan or a plan in the event of an emergency. The registered person was able to talk about the risks to the business but these weren’t documented.

The provider had introduced several policies since the last inspection, however the policies we reviewed did not have a review date. A policy should be reviewed at a regular interval to ensure they were relevant and up-to-date with any changes in guidance. When we discussed this with the provider, they were aware it was good practice to review certain policies at regular intervals, although we could not be assured there was a process to ensure this would be done in a timely way. Staff we spoke with stated they were able to access the policies.

There were some audit processes however these were used to inform business performance rather than to inform quality of care.

The sonographer’s training and competencies were overseen by their NHS trust where they worked. The registered manager had evidence of the training completed but did not have evidence or assurances of competencies, for example the quality of scans completed.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. This had improved since the last inspection. The service was able to refer to other providers when the need arose and were able to do this in a structured way which was documented and complied with information governance and regulations. We saw the provider had received positive feedback on the service it provided for a local private hospital.

The service did not have processes to support continuous learning, innovation and improvement. The service did not have scheduled meetings to discuss learning, improvement or innovation. There was not a dedicated time to consider these aspects of the service provision. However, staff felt able to raise improvement ideas with the registered person, for example the sonographer suggested introducing transvaginal scanning to the service so it could offer both abdominal scans and transvaginal scans. The sonographer said they were supported to do this with the registered person. They wanted to introduce this service to reduce the number of referrals made to the local NHS trust and to ensure people did not require any more scans than was necessary.