Tiny Toes Scan 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

This is the first assessment for this newly registered service. This key question has been rated as good. This meant the service was consistently managed and well-led.

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

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 shared vision, strategy and culture.

Staff focussed on creating a positive patient experience and sought feedback to make positive changes.

The service had a vision for what it wanted to achieve and workable plans to turn it into action. The registered manager could explain how they were working to deliver high quality care.

The evidence showed a good standard. The service had inclusive leader who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce. Leader had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leader had the skills, knowledge and experience to perform their role. As a sonographer, leader and registered manager they promoted a positive culture that supported and valued the future of Tiny Toes Scan Studio, creating a sense of common purpose based on values. They were visible and approachable for service users.

The registered manager/sonographer had a good understanding of the services they managed.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Service users had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Staff had access to the feedback and used it to make improvements.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service currently does not have any other staff members at present; a receptionist was recently recruited and is currently going through employment checks.

There was an equality diversity and inclusion policy with the purpose of ensuring fairness for all in addition to an equality impact assessment policy whose purpose was to help to evidence and understand the differential impact that a decision may have on different groups of people covered under the Equality Act 2010.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

The registered manager had overall responsibility for quality monitoring. This included investigating incidents and responding to patient complaints. At the time of inspection there were no ongoing investigations.

The service carried out some local audits. The audits were sufficient to provide assurance and acted on the results when needed.

Given the small size of the service, the service did not hold a local risk register; however, internal, and external risk assessments were completed for any identified risks.

The service did not use formal key performance indicators to monitor performance. However, the service used patient feedback, complaints, to help identify any necessary improvements and ensure they provided an effective service.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The service was aware of the requirements of managing a service users’ personal information in accordance with relevant legislation and regulations. General Data Protection Regulations (GDPR) had been reviewed to ensure the service was operating within them.

Service users records and scan reports were easily accessible and were kept secure. Paper records were stored in locked filing cabinets, and all electronic records and systems were password protected.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service had a close connection with local NHS providers, local authority and those providers providing similar service. The registered manager told us they were able to access support if or when needed.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement. The service actively contributes to safe, effective practice and research.

The registered manager was passionate about the care they delivered. They had an interest in expanding the service which would require additional staffing and resources.

Staff completed additional training courses to improve and develop their knowledge within their sonography role and as the registered manager.