The Care Quality Commission
  • Hospital
  • Independent hospital

Baby Ultrasound Clinic Limited

Overall: Good read more about inspection ratings

3 Church Bank, Bolton, Greater Manchester, BL1 1HX 07534 012221

Provided and run by:
Baby Ultrasound Clinic Limited

All Inspections

25 October 2022

During an inspection looking at part of the service

Our rating of this service improved. We rated it as good.

This was a focused, unannounced inspection. The inspection followed up a previous inspection in June 2022 which had been a focussed, unannounced inspection in response to specific areas of concern. We did not rate the service as we only inspected the key lines of enquiry within the safe and well – led domains.

Following the June 2022 inspection, we served the provider with a Warning Notice under Section 29 of the Health and Social Care Act 2008. The warning notice told the service that they needed to make significant improvements in their governance processes to ensure the quality and safety of services provided. The provider sent the CQC a report with the actions that they were taking to meet the requirements.

At this inspection, the provider had made improvements.

  • The service provided mandatory training to staff and all staff were up to date with basic life support training. The service had a process that ensured staff were reminded to renew their training when required.
  • The registered manager and staff had completed the relevant training in safeguarding. They had a process in place, which was in line with their policy, which kept women safe, if a safeguarding concern was identified.
  • The service managed infection risk well and had implemented more measures to protect service users and staff from infection. The service had robust systems for cleaning of the scanning beds and had removed equipment that we had identified as problematic at the last inspection. The premises and the equipment was visibly clean.
  • The design, maintenance and use of facilities, premises and equipment kept people safe.
  • The staff completed risk assessments for women using the service. Staff were confident in how they would respond to foetal abnormalities which may be identified or if a women’s health was to deteriorate.
  • The service had enough staff to provide a safe service. We were assured that staff had the correct qualifications, competence and experience to complete their roles.
  • The records relating to the care and treatment of service users were appropriately completed. Women’s records were stored securely.
  • The process for reporting incidents was in place and in line with the services policies. The manager investigated the most recent incident and shared learning with the team. Staff had received training on the duty of candour, and it was evident that their knowledge of this area had improved.
  • The registered manager had the skills and abilities to run the service and demonstrated a better understanding of the priorities and issues the service faced. They supported their staff to develop and take on more senior roles.
  • The service did not have a specific vision or strategy, but the registered manager and staff identified the services main priority as customer experience.
  • The staff felt respected, supported, and valued. The registered manager was aware of equality and diversity in daily work and provided opportunities for career development.
  • Leaders operated effective governance processes. Staff were clear about their roles and accountabilities.
  • Leaders and teams used systems to manage performance effectively.

However,

  • Women’s scan records were not always signed and dated.
  • The scheme of delegation still required some work to fully embed. There was some ambiguity around who staff should contact if the registered manager was unavailable.
  • The services website had not been updated from the previous inspection and still stated that diagnostic scans were being offered, despite the registered manager being clear that this was not the case.

07 June 2022 and 25 June 2022

During an inspection looking at part of the service

This was a focused, unannounced inspection in response to specific areas of concern, we did not rate this service as we only inspected key lines of enquiry within the safe and well-led domains. The service had not been inspected or rated previously.

  • Not all staff providing care or treatment to service users had the qualifications, competence, skills and experience to do so safely as staff had not received all relevant training. The service did not keep comprehensive mandatory training records and ensure all staff had completed the relevant training.
  • The service did not ensure that staff had the appropriate safeguarding training at all levels. We could not be assured that staff would be able to identify safeguarding concerns and report them appropriately.
  • The service did not always ensure the safety of their premises and equipment within it.
  • The service did not have effective systems to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity.
  • Records relating to the care and treatment of each person using the service were not always fit for purpose in particular relating to consent.
  • Staff did not always recognise and report incidents and near misses.
  • The service did not maintain secure records in relation to persons employed in the carrying on of the regulated activities regarding their competency and suitability to perform their roles.
  • The manager did not always understand and manage the priorities and issues the service faced.
  • The provider did not have plans in place to cope with unexpected events.
  • Leaders did not operate effective governance processes throughout the service. They did not use systems to manage performance effectively. They did not always identify and escalate relevant risks and issues nor take action to reduce their impact.
  • The service did not ensure appropriate COVID screening was completed for women and visitors.

However:

  • Leaders were visible and approachable.
  • Staff felt respected, supported, and valued. They were focused on the needs of the women receiving care. The service had an open culture where staff could raise concerns without fear.

Following our onsite inspection, we served the provider with a Warning Notice under Section 29 of the Health and Social Care Act 2008. The warning notice told the service that they needed to make significant improvements in their governance processes to ensure the quality and safety of services provided.

29 January 2019

During a routine inspection

Baby Ultrasound Clinic Limited provides pregnancy keepsake scans to self-paying members of the public. The scans are abdominal and include 2D, 3D and 4D keepsake scans and gender scans. The clinic did not provide diagnostic scans.

The clinic had a waiting room, a scanning room, a toilet, a small kitchen area and a room with baby equipment on show for the public to purchase.

The clinic is based in Bolton and employs a radiographer and a receptionist. The manager was based at the clinic but also spent time at the other three locations across the North of England.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 29 January 2019.

To get to the heart of patients’ 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.

The main service provided was baby keepsake scanning.

Services we rate

We rated it as Requires improvement overall.

  • Recruitment processes were not operated effectively.
  • The provider did not have a system or process in place to ensure policies reflected current practice or were followed by staff.
  • Not all staff were sufficiently trained or understood how to identify and protect service users from abuse or harm.
  • The service did not always control infection risk well.
  • The service had suitable environment and equipment, but these were not always looked after.
  • The service did not always take account of patients individual needs.

However:

  • Staff were competent for their roles and had completed mandatory training.
  • People could access the service when they needed it.
  • Staff treated patients with dignity and respect and involved patients and those close to them in decisions about their care.
  • Concerns and complaints were investigated and treated seriously.
  • The service engaged with customers and staff and took action to improve the service provided.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals