Tiny Toes Scan Studio

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 is the first assessment for this newly registered service. This key question has been rated good.
Activities:
In the reporting period March 2025 to October 2025 the service saw 397 women.
All patients were privately funded.
Track record on safety:
• The service reported 0 never events, serious injuries or incident and 0 complaints from March
2025 to October 2025.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Lessons were learnt to continually identify and embed good practice.

The service has not had any never events of serious incidents since it opened.

The registered manager was aware of the requirements for reporting incidents to the CQC using the statutory notification route if this met the criteria, under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. The unit had applied the duty of candour in applicable situations we were made aware of. Staff were aware of their responsibilities and when the duty applied. The Duty of Candour policy was easily accessible for staff and was in date.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care.

The service users attending the ultrasound were private patients. The referral processes ensured that all essential information about the service users was received to determine if their needs could be safely met.

Staff involved all the necessary healthcare and social care services if a follow up referral was required.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately.

Safeguarding policies were in place for children and adults, these were in date and version controlled; they contained links to legal, professional and national guidelines.

Staff understood how to protect service users from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

The service used the local council’s policies. Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate, and could give examples of how to protect people.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff followed safe procedures for children visiting the service.

Although the service did not provide ultrasound services to adolescents under the age of 18 years, children frequently attended ultrasound scan appointments with their mothers. From review of the registered manager/sonographer’s file we saw that they had received safeguarding children and safeguarding adults training level 3.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with service users so that they understood the process of having an ultrasound, including finding effective ways to communicate with patients with communication difficulties. All additional support required by the service were documented by the service users through the online booking system.

Staff enabled people to give feedback on the service they received for example, via social media.

All service users’ scans were for non-clinical purposes and there was no diagnosis involved. Due to this there was no risk assessment done for people attending for a scan. People were made aware of this beforehand and signed a legal disclaimer to say they understood this was the case.

Staff advised service users about the importance of still attending their NHS scans and appointments. The sonographer made sure people understood that the ultrasound scans and screening tests they performed were in addition to the routine care they received as part of their maternity pathway. The terms and conditions for the service clearly explained this.

Staff followed the ‘Pause and Check’ checklist devised by the British Medical Ultrasound Society (BMUS) and Society of Radiographers. Scan reports were completed immediately after the scan had taken place, which we observed during our inspection.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed and updated risk assessments associated with the environment such as fire extinguishers. They kept clear records and asked for support when necessary.

The service had suitable premises and equipment and looked after them well.

The service was on the ground floor, comprising of a combined imaging and consultation room, a reception and a waiting area. There was an ultrasound machine and associated ‘short form’ couch. There was a television on the wall which mirrored the ultrasound machine and was positioned so people could see it.

The environment in which the scans were performed was spacious, homely, and well arranged. Staff turned the lights off when undertaking a scan to darken the room, which meant scans could be observed clearly. Soft relaxing music was played at low level in the background to enhance the relaxing environment.

The sonographer locked the clinic room door during the ultrasound scans to promote privacy and dignity.

Equipment was PAT tested and serviced; we saw evidence of certification and stickers on equipment we inspected. Each time the service opened the registered manager carried out a routine safety check. Should the service experience equipment breakdown, they had 24 hours a day equipment support. We saw evidence of completed checklist on inspection, along with a cleaning check list that was completed daily along with monthly deep cleaning rota.

Waste was handled and disposed of in a way that kept people safe. Staff used the correct system to handle and sort non-clinical waste.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

The service was provided by a sonographer, who was also the registered manager. They worked in the NHS as a sonographer in addition to this role. The service recently recruited a receptionist, who was currently going through employment checks prior to starting in their role.

The sonographer was required to work as a ‘lone worker’ but followed their lone working policy. The service did not use any bank or agency staff. The service had a chaperone policy in place, chaperoning arrangements were made during booking process; the service does not provide intimate examinations at present and currently do not provide a chaperone.

The service provided mandatory training in key skills and kept a training matrix that was RAG (Red, Amber, Green) rated including due and expiry dates. We saw that the registered manager/sonographer was up to date with all their training.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Flooring throughout the clinic was well maintained, visibly clean, and in line with national requirements. The storage area and the WC at the back of the building was carpeted; however, no clinical procedures were carried out in those rooms. The registered manager stated they were planning to remove all carpets in the very near future.

Disposable paper towel was used to cover the examination couch during the scanning procedure. This was changed between each service users. Adequate personal protective equipment was available, which included disposable gloves. We observed staff using equipment appropriately during each interaction, only transabdominal ultrasounds were carried out at this service.

Cleaning records were up to date and demonstrated that all areas were cleaned regularly. Staff adhered to infection control principles, including handwashing. We saw audits were carried out by external auditor to ensure 1 staff member followed correct process and did not mark their own work.

A risk assessment for Legionnaires’ disease had been completed, and the registered manager was able to demonstrate their understanding of legionnaires prevention. Legionnaires’ disease is a serious pneumonia caused by the legionella bacteria. People become infected when they inhale water droplets from a contaminated water source such as water coolers and air conditioning systems.

The service did not use any controlled drugs or medicines.

Staff were able to demonstrate their understanding around service users attending for ultrasound who may carry an EpiPen. An EpiPen is an epinephrine auto-injector used for the emergency treatment of severe allergic reactions, a condition known as anaphylaxis. The device delivers a single, pre-measured dose of the drug epinephrine (also known as adrenaline).

Staff told us they kept an emergency sugary snack such as a chocolate bar, in case people arriving for a scan may have low blood sugar or become lightheaded.