MYM Coventry

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

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 women 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 is the first assessment for this service. However, we inspected this service as a satellite clinic under a different registration in January 2025, and this key question was rated requires improvement. During this inspection, this key question has been rated good. This meant women’s needs were met through good organisation and delivery.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of women and their communities.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. Leaders had a clear vision and strategy centred on delivering a safe, memorable and family-focused scanning experience in a welcoming environment. Staff were involved in developing and implementing the service strategy and understood how their roles contributed to achieving its goals. It had been implemented in November 2025 and was on display in the service waiting room for staff and women to see. The service values were embedded in daily practice and guided how staff delivered care, interacted with women and families, and promoted safety and continuous improvement.

Leaders had a good understanding of the service’s performance and were focused on continuous improvement. Staff were positive about changes made since the previous inspection and felt involved in planning and shaping future developments.

The culture was open, inclusive and person-centred. Staff were focused on meeting the needs of women and families, promoting equality and diversity, and encouraging people to raise concerns or provide feedback. Staff felt respected, supported and valued by leaders and described positive working relationships, strong teamwork and collaboration.

Individual and team contributions were recognised and celebrated, helping to maintain staff engagement, motivation and a shared commitment to delivering high-quality care.

Staff felt motivated about the future and planned changes for the service. Staff commented positively on improvements implemented by leaders and managers since our previous inspection in January 2025.

Team and individual staff achievement, and success was recognised and celebrated. Staff were thanked for their work.

The service had leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders usually had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on outcomes and experience.

During our previous inspection in January 2025, we found not all leaders understood the context in which the service delivered the treatment and support. Leaders did not always have the skills, knowledge and experience to lead effectively. The registered manager had failed to ensure the clinics were appropriately registered as locations to carry out regulated activities and to scan children. The Coventry clinic was carrying out regulated activities without being registered. During this inspection, we found significant improvements had been made.

The registered manager did not provide any operational oversight at the time of our inspection. An operations manager had been identified to take on the registered manager role and at the time of our inspection, they were in the process of applying for this.

The service had updated its registration following our previous inspection. The Coventry service had been removed as a satellite clinic and appropriately registered as a location. Policies had been updated to ensure appropriate checks were carried out to clarify a woman was not under the age of 18.

At the time of our inspection, the service was going through a change in management structure and oversight. A studio manager had been responsible for the service but was leaving the business the following week. The service was led by an operations manager who had full oversight of the service and were supported by a clinical lead. The operations manager and clinical lead reported into the managing director. Both had been working closely with the studio manager for Coventry to ensure a smooth handover of operational and clinical leadership of this location.

Leaders had a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service for women, families and staff. Staff felt the leaders supported them to develop their skills and improve the service. They considered managers to be accessible and approachable. A management rota was displayed so staff knew who to contact for advice and support.

The service had strengthened its safeguarding leadership since our previous inspection, with 3 managers trained to safeguarding level 4. Staff knew who the leads were and were confident in contacting them for support.

Leaders were able to clearly articulate the service and made sure all staff had relevant experience placing emphasis on the desire for all staff to have had previous experience in health care roles. Leaders placed value in developing opportunities for staff and created individualised development plans with staff. For example, they had updated an induction package for new staff. They were passionate about ensuring staff were appropriately trained and planned to secure accredited sonography training for sonographers.

Leaders had responded positively to a warning notice served in January 2025 and concerns raised following the inspection. They were able to describe actions they had taken to improve following this, and we were assured through our inspection, improvements had been made. Leaders had taken incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders attended the service to assess for themselves how the service was running. They have carried out mock inspections at other locations and shared the learning. The management team were highly passionate and motivated to drive the service forward.

Staff were provided with opportunities to feedback to managers. They were in the process of carrying out a staff survey, but this had not been implemented at the time of our inspection.

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

The service promoted an open and transparent culture where staff felt able to raise concerns and share ideas. A whistleblowing policy provided clear routes for confidential reporting, including access to an independent senior leader and external organisations for support.

Staff told us they felt listened to and supported to raise concerns without fear of detriment. They provided examples of concerns being acted on promptly, demonstrating leaders responded appropriately to issues raised. Leaders investigated concerns sensitively and maintained confidentiality where required. Staff were positive about how open and responsive leaders were to feedback.

Women and their families were provided with information about how to raise concerns or complaints. The service website had been updated to make it easier to make a complaint. Clear processes were in place to manage feedback and complaints, and staff were encouraged to resolve issues promptly wherever possible.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

The service was made up of 7 staff who all championed equality and diversity. There was an equality, diversity and inclusion policy and all staff completed training that supported them to deliver care in line with the policy. This ensured people with protected characteristics as defined in the Equality Act 2010 were able to receive care without bias.

Flexible working arrangements were available, and staff provided examples where leaders had supported them with adjustments for personal reasons. Managers understood where reasonable adjustments or flexibility may be needed, for example, to support pregnant staff or staff with a disability.

Leaders acted to improve where there are any disparities in the experience of staff with protected equality characteristics. We observed pregnancy risk assessments were in place to ensure pregnant women were safe and fully supported at work. This included exploring reasonable adjustments and support to attend maternity appointments.

Managers made sure all staff had access to appraisals regardless of role and responsibilities.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act 2010 and those from excluded and marginalised groups. Staff felt everyone was treated fairly and they would be able to report behaviour or attitudes which were negative in style.

Governance frameworks were not always effective in identifying non-compliance with safe recruitment checks and ensuring organisational policies reflected national guidance. However, the service generally had clear responsibilities, roles, and systems of accountability or good governance. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Governance arrangements had been reviewed at provider level and implemented within MYM Coventry. The service demonstrated significant improvements had been made since our previous inspection in January 2025 to embed a governance and assurance framework. However, during our inspection, we identified some concerns that had not been identified through these governance processes. This included the quality of policies and procedures and oversight of safe recruitment practices.

The systems in place for updating policies and procedures were not always effective in ensuring they were in line with national guidance, legislation, best practice and provided staff with clear procedures and expectations. For example, recruitment, disclosure and barring service (DBS), safeguarding and confidentiality policies lacked detail and some included outdated references, which did not provide full assurance operational policies consistently supported evidence-based practice. However, managers had taken action to improve policy management. All clinical policies were aligned to most up to date guidance. They had revised their documentation and implemented a policy sign off process. There was a plan to review all policies to ensure they were up to date. Immediately following our inspection, managers revised their DBS and recruitment policies to ensure they provided detail for staff and reflected most up to date guidance.

Recruitment audits had not identified gaps in DBS checks or employment references, despite these having been raised at our previous inspection and therefore did not provide full assurance appropriate action had been taken.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them. For example, staff understood how to carry out an audit of health and safety of the building and clinic rooms.

The service had implemented a governance structure, enabling improved communication from staff delivering the service to managing directors and owners of the business. Leaders made sure accurate information was discussed and shared with key staff. Quarterly senior management and monthly local management meetings took place. These meetings fed into service level team meetings. Financial sustainability, operational performance and quality oversight were discussed at all levels. Managers had a good understanding of the pressures and risks. Key updates were provided to staff in team meetings and through regular newsletters.

Quality assurance processes were established and regularly implemented. Improvements had been made to the audit programme, and regular monitoring of clinical, safety and performance indicators supported service oversight and continuous improvement.

Leaders had oversight of operational performance and quality measures through a performance dashboard. This had been implemented following our previous inspection and used to provide oversight to managers. Data was regularly analysed to determine access to the service and specific scans, quality performance including rescan rates and incorrect gender, complaint overview and financial projections.

The service took a proportionate approach to risk management. Risks were clearly identified and a formal log of these was used to keep oversight and manage mitigations and/or bring to resolution. The risk register was reviewed regularly by managers. It included clinical, environmental and business risks, and documented how these risks were mitigated. There was a service level risk register which was reviewed twice a year and fed into the provider level risk register. We were assured the risk register reflected risks we identified on site.

Managers understood their regulatory responsibilities. The registered manager had sold the business at the time of the inspection and was no longer working operationally. They remained a shareholder and contributed to provider level governance processes. An operations manager was in the process of applying for the position. Local leaders maintained effective operational oversight and understood regulatory responsibilities.

Managers implemented a competency assessment framework for assurance sonographers were working within their scope of practice and were regularly supervised and monitored. This included peer reviews, reflective accounts and supervision. There were processes to share learning from incidents and complaints, at both senior leadership and service level.

The service had plans to cope with unexpected events and had a business continuity plan, which included major incident plans. They had both public and business liability insurance which was displayed.

Arrangements for the availability, integrity, security and confidentiality of data were in place. Records were stored securely on an electronic system. Permission to store and share information was sought and documented electronically.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for women. Staff share information and learning with partners and collaborate for improvement.

The service had close connections with local NHS early pregnancy and maternity units. The team had made connections in the local hospitals and other relevant services. The management team planned to make more and stronger links with local community providers.

The service worked in alignment with other MYM services. The operations manager and clinical lead worked across other locations to ensure governance processes were aligned and to share good practice to improve consistency.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for women. Staff actively contribute to safe, effective practice and research.

Staff were committed to continually learning and improving services. The service had responded positively to concerns raised at our previous inspection and we observed improvements across all areas including staff training, infection prevention and control, the environment and governance arrangements. Staff acknowledged they had made significant improvements and there were further improvements required. Managers and staff knew what these areas for improvement were and we observed they were working towards this. Leaders were observed to be highly motivated and passionate to drive improvement and work towards an outstanding service.

There were processes for learning when things went wrong or of good practice, either locally or nationally. For example, managers reviewed all incorrect genders and referrals for maternity care to review the images, reports and sonographer approach. They used this positively to identify good practice and to share learning across the service and other locations. We saw evidence of continued learning and improvement across the service in documented team meeting and governance meeting minutes.

Staff and managers shared learning across the organisation. For example, a mock inspection took place at another location, and the learning was shared with MRM Coventry who had used this to make local improvements.

Staff were supported to have the time to develop their skills around improvement and innovation and to pursue areas of interest in the service. Staff were given time to complete mandatory training and time to develop their practice. For example, a competency framework had been implemented, and all existing staff had been given opportunity to learn and were assessed against this over a period of time. All new staff were given on the job training in line with the competency assessment.