MYM Coventry

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that women and communities had the best possible outcomes because their needs were assessed. We checked that women’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring women were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This is the first assessment of this service. However, we previously inspected this service as a satellite clinic under a different registration and rated this key question requires improvement. At this assessment the rating has been assessed as good. This meant outcomes were consistently good, and feedback confirmed this.

We have not awarded this service a score for Effective.

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

The service usually made sure women’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Women's needs were assessed before care and treatment was provided. The service had clear inclusion and exclusion criteria, which staff understood and applied consistently. Booking information was reviewed prior to appointments to identify potential risks and ensure scans were appropriate for the individual. Staff monitored repeat bookings and discussed the suitability of appointments where women had requested multiple scans within a short period or were under 18.

Staff used approved scanning protocols embedded within ultrasound equipment to support consistent and safe practice based on assessed needs.

Women were provided with information to help them prepare for their appointment, including full bladder requirements where appropriate. Staff considered individual needs during scanning and supported women to achieve comfortable positioning to enable a positive experience. These processes helped ensure care and treatment were appropriate, safe and tailored to people's needs.

The service did not always plan and deliver care and treatment with women, including what was important and mattered to them.

Service policies and procedures were not always aligned with current guidance and best practice. Since our previous inspection in 2025, improvements had been made to policy management, including reviewing policies, assigning ownership and review dates, and making them accessible to staff. However, further work was required. Some policies lacked sufficient detail to support consistent practice and did not fully reflect current legislation or best practice. For example, the recruitment and disclosure and barring service (DBS) policies were not sufficiently detailed, the safeguarding policy incorrectly referenced the Mental Capacity Act 2019 rather than 2005 and did not clearly demonstrate how the service met the principles of Working Together to Safeguard Children (2023). In addition, the confidentiality policy continued to reference outdated data protection legislation and did not include reference to UK General Data Protection Regulation (GDPR). As a result, we were not assured operational policies fully supported evidence-based practice. Leaders were receptive to feedback and took immediate action following our inspection to review and revise policies. We were provided with a revised recruitment and DBS policies which provided more clarity for staff and more aligned with up-to-date guidance.

Sonographers practised in line with current national guidance and evidence-based practice. Clinical policies reflected guidance from the British Medical Ultrasound Society (BMUS), and staff were trained in line with the Society of Radiographers’ competencies for ultrasound practice in private baby scan clinics (2022). Competence was monitored through quarterly observations using a structured competency framework. Ultrasound equipment was pre-programmed to support staff to work within the scope of practice recommended by BMUS and the Society of Radiographers.

The service followed the As Low As Reasonably Achievable (ALARA) principles and staff adhered to the nationally recognised ‘Pause and Check’ process before scanning. This meant sonographers used minimum frequency levels for a minimum amount of time to achieve the best result.

Systems were in place to communicate updates to guidance, including team meetings, newsletters, notice boards and weekly staff bulletins.

The service usually worked well across teams and services to support women. Staff made sure women only needed to tell their story once by sharing their assessment of needs when women moved between different services.

Staff worked collaboratively to provide coordinated, person-centred care. Sonographers and reception staff communicated effectively before, during and after appointments, supporting each other to ensure women received a positive experience. Feedback, learning and service updates were routinely shared between teams to promote consistent practice and continuous improvement.

The service worked effectively with external healthcare providers to support continuity of care. When concerns were identified, sonographers made timely referrals to NHS Early Pregnancy Assessment Units (EPAU), contacting services directly to facilitate prompt access to care. Women were provided with scan images and relevant information to support onward assessment. Staff described positive working relationships with NHS services and told us concerns were responded to appropriately, helping to ensure women received the care and support they needed.

The service supported women to manage their health and wellbeing to maximise their independence, choice and control. The service supported women to live healthier lives and where possible, reduce their future needs for care and support.

The service supported women and families to make informed choices about their health and wellbeing by providing clear information about available scans, what to expect during appointments and how to prepare for them. Staff explained the purpose and limitations of scans and signposted women to appropriate healthcare services where further assessment or support was required.

Health promotion information was available within the clinic and online, including advice on recognising symptoms requiring medical attention, healthy pregnancy initiatives, smoking cessation in pregnancy and maternal vaccination programmes. Information on baby loss support services and financial support schemes for families was also readily available.

Through information, advice and signposting, staff empowered women to make informed decisions about their care and access additional support to promote healthy pregnancy outcomes and family wellbeing.

The service monitored women’s care and treatment to continuously improve it. Staff ensured outcomes were positive and consistent, and they met both clinical expectations and the expectations of women themselves.

The service used performance data to monitor outcomes and drive improvement. Quality indicators such as complaints, re-scan rates, incorrect gender determinations and referrals were routinely reviewed to identify trends and areas for learning. Managers investigated variations in performance and considered factors that may influence outcomes, using findings to inform service improvements. For example, from June 2025 to May 2026, there were 4 incorrect gender determinations. Managers considered this was within the expected range. These incidents were reviewed, and appropriate learning and support were provided to staff. Re-scan rates remained stable at 6.86% from January to June 2026 and were reviewed monthly to identify any unusual variation and support sonographer development where required.

The service monitored potential abnormalities identified during scans and subsequent referrals. However, staff did not routinely follow up outcomes with women or local EPAUs to inform service learning, although leaders had sought to strengthen links with local services.

Complaint data was reviewed to improve outcomes and shared across locations to support organisational learning. Managers benchmarked performance against other clinics and investigated areas of variation. For example, additional support was provided to improve reception processes following feedback from complaints.

Improved clinical governance processes supported continuous improvement. Sonographers underwent competency assessments, peer image reviews and regular supervision, with additional training and support provided where required. Managers also completed regular audits of the environment and equipment to identify and address issues promptly.

The service did not always tell women about their rights around consent and did not always respect their rights when delivering care and treatment.

The service had a consent policy in place; however, it did not fully reflect current legislation and best practice. The policy did not reference the Mental Capacity Act 2005 (MCA), provide guidance on assessing and documenting capacity, or clearly set out requirements for recording consent and the right to withdraw consent.

Staff had not received specific MCA training and could not clearly explain how they would assess or document a person's capacity to consent. While staff recognised when concerns about capacity should be escalated, their understanding of the legal requirements of the MCA was inconsistent. However, staff told us if they had a concern, they would always speak to their manager before scanning. Furthermore, managers told us MCA was a learning objective included in their mandatory safeguarding training. Managers confirmed following our inspection, MCA and Deprivation of Liberty Safeguard (DoLS) training would be introduced in September 2026 for appropriate staff.

Staff supported women to make informed decisions and consistently explained the purpose and limitations of scans before obtaining consent. Women were provided with information at booking and prior to scanning. Verbal consent was sought throughout appointments. For example, staff checked women were happy for others to be present, to apply ultrasound gel and to start scanning. Staff also sought permission before sharing information with family members or others.

Consent was documented through online consent and waiver forms completed at booking or on the day of the appointment and retained within records. Age verification checks were also completed before scans were undertaken. However, gaps in policy content and staff knowledge meant the service could not be assured all aspects of consent and capacity were managed in line with current legislation and best practice.