Baby I Love You Limited

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• 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 means we looked for evidence that people were protected from abuse and avoidable harm.

This was the first rated assessment for this service since 2019. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had developed an incident reporting policy which outlined the procedures for reporting, managing, investigating, and learning from all clinical and non-clinical incidents. This applied to ultrasound scanning procedures, phlebotomy (venepuncture and sample handling), and non-clinical incidents, such as data breaches, equipment failure or environmental risks.

The policy identified that all incidents and near misses were to be reported promptly and accurately, managed to minimise risks to patients, staff, and visitors, and appropriate action taken to minimise harm.

The policy outlined staff roles in the event of an incident, timelines and referenced the duty of candour, a requirement for health and social care providers to be open and honest with patients and their families when something goes wrong in their care that causes or has the potential to cause moderate harm or worse.

Although no incidents had been recorded, we found the registered manager was able to demonstrate a clear knowledge of reporting, investigating, and the process of sharing incidents with staff and understood their responsibility to report any notifiable incidents. The registered manager confirmed incidents and complaints would be discussed in team meetings and was included on the regular agenda.

Staff we spoke with knew how to report serious incidents or adverse events.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Referral and admission processes ensured all essential information about the patient was used to determine if the patient’s needs could safely be met. Patients booked appointments by telephone, email or through dedicated social media platforms, after which the required booking information was obtained by the service. The sonographer asked relevant health questions at the time of treatment.

The service had a phlebotomy services policy and procedures in place which covered UK Health Security Agency (UKHSA), Health and Safety Executive (HSE), and infection prevention guidance. All phlebotomy staff held appropriate qualifications and competency sign-off, undertake annual updates in infection control, sharps safety, and basic life support and maintained evidence of continuing professional development.

Standard infection prevention precautions were followed, such as hand hygiene before and after procedures, use of appropriate personal protective equipment (PPE), aseptic non-touch techniques, and environmental cleanliness and waste management. All staff undertaking exposure-prone procedures had documented evidence of hepatitis B immunity

All patients were screened at the time of booking against clear exclusion criteria and assessment of individual risks. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service had clear guidelines for unexpected findings and onward management of patients through the North East and Cumbria Maternity Clinical Network.

Patient records were kept securely in line with the service information governance policy. This ensured compliance with all relevant data protection legislation, protected personal and sensitive data, maintained patient confidentiality, and ensured safe and secure handling of information.

We scored the service as 3. 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. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had policies in place for safeguarding adults and also safeguarding children. These committed the service to ‘…providing a safe, respectful and welcoming environment for everyone who uses or visits…’ the service.

To achieve this, the service had a zero tolerance of abuse, neglect, discrimination, harassment, degrading treatment or exploitation. We saw evidence of this through the one safeguarding concern the service had raised to the local authority safeguarding team. This related to staff observing behaviour that they considered inappropriate and potentially harmful to a child.

The policies identified the legal safeguarding framework, defined risk, abuse and neglect, as well as good practice, professional boundaries and how to recognise indicators of abuse and neglect. The mechanisms for responding to concerns through taking immediate actions and reporting concerns were clearly identified. The service had also developed a female genital mutilation (FGM) and prevent policy with the responsibility of all staff to safeguard all patients through the recognition and reporting of FGM.

The service had identified one member of staff as the safeguarding lead, trained to safeguarding children level 3 and safeguarding adults level 3, all other members of staff had received safeguarding adults and children training level 2 and annual updates. Staff knew how to make a safeguarding referral when necessary.

We scored the service as 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.

The service health safety and CPR (cardio-pulmonary resuscitation) policy committed the service to compliance with health and safety legislation, completion of risk assessments, ensuring staff received appropriate training, reviewing accidents, incidents, and near misses, and learning was embedded into practice. This framework meant the service worked well with people to understand and manage risks, initially through the completion of a booking form and also individual risk assessments.

The booking form included personal details, details of the patient’s general practitioner and surgery, and pregnancy details (midwife and date of last hospital ultrasound). Additionally, gestation (weeks), problems during pregnancy and state of health were recorded.

The patient was required to confirm they understood their scan had not been arranged by their GP and did not replace GP, midwife or hospital care, and the scan followed British Medical Ultrasound Society (BMUS) recommendations for frequency and length of scan. This was complemented by a foetal wellbeing check detailing heartbeat, movement, presentation and foetal presentation.

The service did provide patients with ‘goody bags’ at their scan which included nutritional supplements. However risks in doing so were not always recognised, and the service did not have a process to safely supply, track, or store nutritional supplements.

We scored the service as 3. 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.

The design, maintenance and use of facilities, premises and equipment kept people safe. The ultrasound system used by the service had last been serviced and quality assured in February 2026. Staff were trained to use equipment and to manage different types of waste safely. Where required areas were secure and gave protection to patients. Access was restricted by keypad access. All single use items were in date.

There was suitable equipment provided and used correctly, such as for patients who needed assistance with their mobility or to transfer onto equipment. Staff carried out daily safety checks of equipment. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

Equipment audits were completed and outcomes shared with staff. Staff told us they had appropriate equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective processes to repair and replace broken or missing equipment.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the service needs; hazardous substances were stored safely.

The service had suitable facilities to meet the needs of patient’s family and friends when necessary. The spacious and well-furnished lounge was bright and welcoming.

A lone working policy was in place to minimise risks mainly within the ultrasound service through robust procedures, clear communication, and appropriate support systems.

The service had enough clinical and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. These included a sonographer and phlebotomist, scan assistants, receptionists and managerial staff. The service had a stable workforce with most staff having worked at the service for a number of years.

New staff had a full induction tailored to their role before they started work, detailed within the service quality assurance policy. Managers supported staff to develop through constructive and recorded annual appraisals, regular one-to one meetings and supervision.

Staff said they were able to take appropriate breaks and felt the service was safe. Patients were very complimentary about how they were welcomed by staff, had their needs met and we saw staff were kind and supportive. All patients said they felt comfortable and were engaged in their care.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had an infection control policy and procedures in place, as well as a needle stick injury policy and procedure applicable to the phlebotomy service. These aimed to protect patients from avoidable infection risks, and embed infection prevention and control (IPC) into everyday practice. The service assessed and managed the risk of infection, detected and controlled risk well.

Patients were protected from the risk of infection as all areas of the premises were kept clean. All areas of the premises were in good condition and were effectively cleaned, with the exceptions of the toilet light pull cord and the thank you cards shelf, however these did not pose an infections control risk. The clinic room had hard surface laminate flooring and the ultrasound machine was visibly clean. The clinic had appropriate cleaning equipment to prevent cross contamination, for example mop buckets and heads for dealing with cleaning needs.

The service had clear processes for monitoring the effectiveness of infection prevention and control. We saw evidence the service conducted regular infection prevention and control (IPC) audits. Daily checks were conducted of the premises and included maintenance, walkways, lighting, spillages, trip hazards, work areas, machinery, furniture, toilet, and ultrasound room and bed.

Staff adhered to infection control principles including hand washing. Staff had access to personal protective equipment (PPE). The sonographer carried out regular handwashing before and after patient contact. Hand sanitiser was available for patients in reception. The ultrasound couch was wiped down after each use and the sonographer used sterile ultrasound gel in date for scans. The service used an external waste collection company to collect and destroy clinical and non-clinical waste.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

We did not look at medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.