MYM Coventry

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Women were safe from neglect, abuse and discrimination. The service had a proactive and positive culture of safety. Sonographers carried out scans within the scope of their practice. Processes to escalate abnormal findings were embedded. Staff had completed mandatory training, and sonographers had undergone competency assessments. The service was clean and tidy and equipment used for scanning had been safety checked.

However, we found recruitment checks and disclosure barring service (DBS) checks had not always been carried out in line with national guidance.

This is the first inspection of this service. It had previously been inspected as a satellite clinic under a different location and safe had been rated as inadequate. Following this inspection, we found improvements had been made and safe had been rated as good. Women 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.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service promoted a positive learning culture, with effective systems in place for reporting, investigating and learning from incidents and complaints. There was an up-to-date significant events policy. The policy outlined details of reportable events with a clear process for review. Staff understood their responsibilities, knew what to report, and used an electronic reporting system to record incidents, including potential abnormalities identified during scans.

From January to June 2026, 54 incidents had been reported, the majority (50) related to concerns or potential abnormalities identified during scans. There were no serious incidents, never events or near misses reported. Incidents were reviewed by managers and clinical leads to ensure appropriate action had been taken, referral pathways followed, and learning identified. Staff received support and debriefing following incidents where required.

The service also maintained an effective complaints process. There was an up-to-date complaints policy. From June 2025 to May 2026, 21 complaints had been received and investigated in line with the policy. Complaints were managed by the head office manager, in collaboration with local teams and clinical leads, to ensure thorough investigation and shared learning. Complaints reviewed demonstrated an apology was given and where required a reimbursement of payments made.

Learning from incidents and complaints resulted in service improvements. For example, the service strengthened data protection processes following a breach and an upgrade to data transfer systems was due to be implemented in July 2026. Clinical learning from identified abnormalities was routinely shared with sonographers in response to good practice and areas for improvement. Learning outcomes were disseminated through management meetings, team meetings, supervision sessions and communication across the providers other locations.

Staff demonstrated an understanding of the duty of candour and were open and transparent when things went wrong. People were encouraged and supported to raise concerns. Women told us they felt comfortable contacting the service for advice, to give feedback or to raise concerns. They were confident they would be listened to and treated with compassion and understanding.

The service worked with women and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for women’s care moved between different areas of a service and between providers.

Safety and continuity of care was a priority. The service had effective systems to ensure people received safe and appropriate care throughout their care pathway. Clear eligibility criteria were in place, and staff screened women before appointments to confirm scans were suitable, including checks of gestation, age and health status. Records demonstrated eligibility criteria were consistently applied.

All women were advised the scans were non-diagnostic and not part of their NHS maternity pathway. Staff checked women were attending maternity appointments and we observed they encouraged women to attend. Staff followed established pathways for each type of scan, ensuring examinations were undertaken at the appropriate stage of pregnancy. They requested gestation information to check the scan booked was appropriate.

There was a strong awareness of the risks to women. The approach to identifying and managing these risks was proactive and effective. A referral policy set out actions staff should take if they identified a concern during a scan.

The service had established contacts with local emergency pregnancy assessment units (EPAU) to support timely and supportive referrals. The service monitored where concerns had been documented and action had been taken. We saw evidence staff regularly signposted and referred women to EPAUs and accident and emergency departments.

Staff supported continuity of care by providing women with relevant scan images and reports, and sharing information with other services, with consent, where necessary. From June 2025 to May 2026, 44 women had been referred to local services for assessment.

Clinical records were maintained securely on electronic systems that were reliable and accessible, supporting effective communication and continuity of care.

The service worked with women and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

During our previous inspection of this service as a satellite clinic in January 2025, we found there was limited evidence of effective safeguarding systems, processes and practices in place to protect people from abuse. Staff were not trained to the appropriate level of safeguarding for their role and staff did not know how to make a safeguarding referral. During this assessment of the location, we found improvements had been made.

The service had safeguarding systems, policies, and practices to protect adults and children from abuse and neglect. A safeguarding children and adult policy had been implemented in October 2025 with planned annual updates. The policy generally reflected national guidance, however, did not reference most up to date legislation such as the Mental Capacity Act 2005 and the Children’s Act 1989. The policy did contain details of the safeguarding leads, definitions of abuse, role relevant training requirements, escalation processes and external reporting processes. Contact details for local multi agency safeguarding hubs were included in the policy. Safeguarding concerns and or referrals were recorded on a safeguarding referral log and reviewed by the management team quarterly.

There was a good understanding of safeguarding and how to take appropriate action. Staff were provided with safeguarding adult and children training appropriate to their role. For example, all sonographers had been trained to safeguarding level 3 and administrative staff level 2. Staff we spoke to recognised signs of abuse and neglect in the context of their role, including signs of domestic abuse or neglect. They described how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff were able to describe steps they should take should they identify a safeguarding concern which was in line with the safeguarding policy.

There were processes to ensure professional safeguarding advice could be obtained through safeguarding leads and the local authority. There were 3 managers trained to level 4 safeguarding for children and adults. There was always a manager on duty who was trained to this level and a rota was displayed on the notice board, so staff had quick access to advice and support. Safeguarding procedures were on display for staff to easily access. Domestic abuse helpline information was on display. Staff were confident raising safeguarding issues and understood how to escalate concerns. However, staff we spoke to had not raised a concern at the time of our inspection.

There were processes to ensure the safety of children attending the service alongside adults. Staff were clear about protocols for children visiting with families. For example, they would ensure there was a family member remaining in the waiting area with a child if the person attending for the scan did not want the child in the scan room.

The service did not offer chaperones but supported women to arrange a chaperone. If a woman wanted a chaperone, appointments were rearranged at no extra cost to enable them to identify someone to attend.

The service worked with women to understand and manage risks by thinking holistically. Staff provided care to meet women’s needs which was safe, supportive and enabled them to do the things that mattered to them.

During our previous inspection of this service as a satellite clinic in January 2025, we found the service did not always work well with people to understand risks. There was a lack of understanding about what to do if someone became unwell. Staff were carrying out scans which were not souvenir scans and were diagnostic. During this inspection we found improvements had been made.

People were supported to understand risks and were involved in managing their care safely. The service had processes to ensure scans were appropriate, including screening at the point of booking. This included confirmation of pregnancy details, recent scans, maternity care provider and a declaration of health status. People could only book a scan based on the information provided. For example, if the person was under 18, they were unable to book the scan. Any concerns were discussed with women prior to scanning.

Risks associated with repeat scanning were effectively managed. The service had a re-scan policy in place, and staff reviewed previous scans to ensure further scans were appropriate. Re-scan rates were monitored, and concerns about excessive scanning were escalated to management. Women were made aware of the risks of frequent scanning, and staff reinforced this during appointments.

Staff demonstrated a clear understanding of their professional limitations in providing non-diagnostic scans. Women were consistently informed, both at booking and during appointments, that scans were non-diagnostic, supplementary to NHS care, and could not assess growth, detect abnormalities or confirm medical conditions. This was supported by a non-diagnostic scan policy, which staff understood and applied in practice.

The service had consent processes in place. Women were provided with clear written and verbal information about risks, including the elective nature of scans and the position of the British Medical Ultrasound Society (BMUS) regarding non-medical scanning. Consent documentation clearly stated ultrasound scans did not replace NHS assessments and was completed at booking and on the day of the appointment.

Scanning practices were in line with national safety guidance. Staff followed the ‘As Low As Reasonably Achievable’ (ALARA) principle and adhered to defined exposure limits. The service had an ultrasound safety procedure, and staff competency was supported through regular observational assessments.

Clear scanning protocols supported staff to deliver care safely and consistently. Protocols were programmed into the ultrasound machines by the manufacturer. Following our previous inspection, the service turned off functionality of the ultrasound machines so diagnostic measurements could not be carried out. Scanning protocols were available for staff to follow for each type of scan. These outlined each stage of the process, including identity checks, consent, communication and escalation where required.

Staff were trained to respond to emergencies and demonstrated a good understanding of the service’s medical emergency policy. All staff had completed training in basic life support and first aid and were confident in responding to emergency situations. A first aid kit was available, in good condition and regularly checked.

There were clear processes for onward referral to NHS services when required. For example, where a concern was identified on a scan, sonographers made a referral to local EPAUs. Staff followed an up-to-date referral policy and made timely referrals, ensuring women were supported to access appropriate care. Referrals were recorded and reviewed by management to maintain oversight.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care.

During our previous inspection of this service as a satellite clinic in January 2025, we found the service did not safely store flammable substances in line with Control of Substances Hazardous to Health (COSHH) regulations 2002. There was a large amount of out-of-date equipment and there was no evidence of environmental risk assessments being carried out. During this inspection we found significant improvements had been made.
People were cared for in clean, safe and accessible environments which met their needs. The clinic was accessible, located on the ground floor with wheelchair access and onsite parking available. Facilities were spacious, uncluttered and provided adequate seating for families in both waiting and scanning rooms. Although there were no onsite toilet facilities, people were directed to nearby amenities within the same site.

Scan rooms were well maintained, comfortable and supported privacy and dignity. They were equipped with height-adjustable couches suitable for a range of needs, including people with reduced mobility and higher body mass index. Scanning rooms were wheelchair accessible. Lighting and viewing arrangements supported a positive experience, and rooms could be secured to ensure privacy.

Equipment and facilities were suitable for their intended purpose and supported the delivery of safe care. Ultrasound machines were pre-programmed to limit use to non-diagnostic scanning. Equipment was clean, well maintained, and serviced in line with manufacturer and the British Medical Ultrasound Society (BMUS) guidance. Staff carried out regular daily and weekly quality assurance (QA) checks, and any concerns were escalated appropriately. Staff reported having sufficient equipment to carry out their roles safely, with processes in place for timely repair or replacement.

The service had effective arrangements to ensure safety of equipment and the environment. Electrical equipment testing, fire safety systems and routine safety checks were in place and up to date. Staff completed fire safety training, participated in twice yearly fire drills and understood their roles in an emergency. An emergency fire evacuation plan was displayed. Fire safety equipment was in good condition, visible and had been safety checked. Evacuation points and fire marshal details were displayed on the wall, and fire exits were clear.
Arrangements for blood testing were safe and well managed. Equipment was securely stored, appropriately labelled and tracked to ensure safe handling and timely processing.

Clinical and non-clinical waste was managed safely, with appropriate segregation and disposal processes in place. Hazardous substances were securely stored, with relevant safety information available to staff. Sharps bins were available, accessible and appropriately labelled. Arrangements were in place to safely dispose of clinical waste.

There were clear systems for monitoring and maintaining the environment and equipment. Daily, weekly and monthly checks were completed, supported by risk assessments and health and safety policies. Leaders maintained effective oversight through audits and monitoring. Audits carried out were thorough and we saw actions in place where non-compliance was identified had been completed.

Recruitment processes did not always ensure staff were suitable for the role and safe recruitment checks were not consistently carried out. However, the service generally made sure there were enough qualified, skilled and experienced staff. Staff were provided with effective support, supervision and development. Staff worked together well to provide safe care that met women and their families’ individual needs.

Recruitment processes did not always ensure staff were appointed in line with safe recruitment requirements. We found some gaps in recruitment records, including missing references and employment contracts in 2 out of 4 staff records we reviewed. The recruitment policy did not clearly set out all safer recruitment checks required for healthcare roles. In addition, Disclosure and Barring Service (DBS) checks had not consistently been obtained at the appropriate level in line with the provider's policy or national guidance. We found 1 sonographer did not have the required level of DBS check carried out. Reception staff were not required to have a DBS check; however they were supervising women and families whilst sonographers were in the clinic rooms. They also took key information from women such as due dates, details about their maternity pathways and scan dates. We were not assured the service policy reflected national requirements.

Leaders responded positively to concerns raised during the inspection and took immediate action to strengthen recruitment processes. The recruitment and DBS policies were updated to reflect national requirements, DBS arrangements improved, and evidence was provided that the required DBS checks had been applied for. For example, sonographers had enhanced checks and reception staff had standard checks. Managers revised their DBS compliance audit, so it was clear about the standards required and would be effective moving forward.

Staffing levels ensured the service was safe and met the needs of women and their families. The service had 3 sonographers and 4 reception staff. They were in the process of recruiting for a vacant reception position. The service was supported by an operations manager and a clinical lead. Staffing levels ensured there was no lone working and there was always access to a manager during service opening times. Managers reviewed service demand and appointment fill rates daily using a live dashboard with service information. Staffing levels were flexed accordingly. The service had low vacancy, turnover, and sickness rates and managers described the team as stable. They did not use any temporary staff but occasionally had experienced staff from other locations to cover in the event of unexpected absence or increased demand.

Staff considered staffing levels were safe. They were able to take breaks during their shift. Women and their families spoken with felt their needs were met in a timely way and we observed staff were responsive and supportive to the needs of women and their families. Women appeared comfortable and were engaged in conversations because there were sufficient staff.

The service had effective systems to support staff training, development and competency. Mandatory training in key skills was sourced through an external accredited health and social care training provider. A system was in place to alert staff when their training was due for renewal. All staff were up to date with mandatory training requirements, including basic life support and first aid. Training on recognising and responding to people with mental health and learning disabilities had been completed.

Managers invested in staff ongoing continuous professional development. Sonographers completed a structured training and competency programme aligned to the Society of Radiographers (SoR) competencies for ultrasound practice in private baby scan clinics 2022. Records reviewed for the most recently recruited sonographer demonstrated they had undergone a competency assessment before they were confirmed in post. Staff underwent quarterly observed competency assessments, as well as being provided with clinical supervision by a qualified sonographer who had undertaken the Consortium for the Accreditation of Sonographic Education (CASE) accredited qualification. In addition, sonographers had quarterly peer reviews and completed quarterly reflections on their practice. Managers provided evidence these were regularly completed.

Staff carrying out blood tests for NIPT had received competency-based training from an external provider.

Staff received induction, appraisal and ongoing support, and told us they felt supported and able to carry out their roles safely.

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.

The service assessed and generally managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

During our previous inspection of this service as a satellite clinic in January 2025, we found infection, prevention and control (IPC) standards were not met. For example we found carpet in clinic rooms where blood was taken, soft furnishings were not wipe cleanable, there was no evidence of toys being cleaned regularly, staff did not know how to manage a bodily fluid spillage, ultrasound scanning equipment was not clean, there were no IPC audits and ultrasound gel bottles were refilled with no opening and expiry date recorded. During this inspection, we found significant improvements had been made.

The service had effective systems to assess and manage infection risks. An up-to-date infection, prevention and control (IPC) policy, cleaning schedules and monitoring processes were in place and routinely reviewed. Daily and weekly cleaning checks, including deep cleaning, were completed consistently, and regular environmental audits provided oversight of cleanliness and hygiene. Whilst the policy set out IPC responsibilities for all staff, cleaning requirements and monitoring arrangements, it did not reflect national IPC guidance. For example, it did not reference BMUS ultrasound probe decontamination guidance.

People were protected from infection because the environment and equipment were clean, well maintained and suitable for their purpose. Women consistently told us the clinic was clean and tidy. The environment included hospital grade flooring and wipe clean furnishings to support effective cleaning. Ultrasound equipment, transducers and couches were appropriately cleaned and disinfected between appointments, and staff followed established decontamination procedures. We saw paper roll was used to cover the couch which was wiped down between each person and fresh paper laid.

Staff used pre-filled ultrasound gel bottles. They were stored appropriately and dated when opened. All equipment for blood taking was stored in individual sealed boxes. Spill kits were available for cleaning of any bodily fluids.

Staff followed good IPC practices. We observed staff washing and sanitising their hands before and after contact with people who used the service, and hand hygiene facilities and guidance were readily available throughout the clinic. Personal protective equipment was available and used when required. Clinical waste and sharps were managed safely, with appropriate segregation, storage and disposal arrangements in place.

The service also had effective arrangements to manage environmental risks, including routine legionella monitoring through weekly flushing of infrequently used outlets.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.