MYM Tamworth

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 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. 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 made sure people’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.

Women were provided with information to help them prepare for their appointment, including whether a full bladder was required. 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 individual’s needs.

Women’s records were comprehensive for the needs of the service, and all staff could access them easily. Staff kept secure electronic copies of scans, along with details of the consent, and referral questionnaire. We saw 5 records, which showed completed risk assessments, consent and scan details clearly recorded. Information was available locally on scanners for a limited period. To enable auditing and recovery of images, all information was sent to a restricted access secure portal.

When women transferred to another team, such as the Early Pregnancy Assessment Unit, there were no delays in staff accessing their records. Women were provided with a copy of their scan immediately after their appointment, and scan details were shared as part of any referral. 

The service offered two types of blood tests. Non- invasive prenatal testing (NIPT), which identifies the chance of certain genetic conditions and gender only testing. Gender blood results were sent directly to the woman, whilst NIPT test results, were reviewed by the service and shared with the woman. These were recorded, and women liaised with their GP or chosen NHS trust for follow up.

All electronic devices were password protected and we saw computers were not left unattended.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. 

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. We saw that policies had recently been updated.  Policies were shared when changes were made and staff had to confirm that they had received and understood the updates. Managers kept a log of policies and dates for review. Policies were discussed at governance meetings and approved prior to being shared.

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). The sonography lead reviewed competency with quarterly scan audits and findings were discussed with individual sonographers to enable learning and development. 

Ultrasound equipment was preprogrammed to support staff to work within the scope of practice recommended by BMUS and the Society of Radiographers. Sonographers were trained to complete non-diagnostic scans only, with the senior sonographers being trained in case reviews. 

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.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of the patient group. Sonographers had varied skills and professional qualifications including registered nurse and allied health professional registration with the Health and Care Professions Council (HCPC).

The service always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff worked across the organisation flexibly and proactively. We were given and saw multiple examples of where staff worked above and beyond their designated roles for the benefit of women, and the service. Staff spoke genuinely about providing a quality service and ensuring their colleagues were supported and able to contact help when needed.

The service had an available on-call manager who could help in the event of an incident or sickness. Managers were flexible, covered reception and clinical lists as necessary if gaps arose, and answered calls for help, even when they were not on call. Managers recognised this was not expected, but enjoyed their work, and wanted to ensure staff felt supported.

Staff worked collaboratively to provide coordinated, person-centred care. Sonographers and reception staff communicated effectively before, during and after appointments, supporting each another 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 lead sonographer had contacted local NHS providers to introduce their service and identify correct pathways to NHS services. We were given examples of where some NHS trusts had provided contact numbers for Early Pregnancy Assessment Units, opening hours of clinics and contact numbers/ referral forms. This had made the process for referring women into NHS maternity units easier. Staff were able to escalate any concerns to the woman’s NHS maternity unit of choice using correct and approved pathways. This ensured that women had continuity with teams and were seen by their own midwives/ team if problems arose.  

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

Staff supported women and families to make informed choices about their health and wellbeing by providing clear information about scans. This included what was involved and how to prepare for them. Staff told women about the purpose and limitations of the scans offered, ensuring additional information/ scanning needs were addressed by the NHS trust. 

Staff discussed healthy lifestyles as part of appointments although there was no formal programme. The service had relevant information promoting healthy lifestyles and support in patient areas. There was advice on recognising symptoms requiring medical follow up, healthy pregnancy initiatives as well as advice for smoking cessation and vaccinations.

Staff were familiar with baby loss support networks locally and were able to signpost women and families if necessary.Information on baby loss support services and financial support schemes for families was readily available.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people 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, the service reported 9 gender errors from June 2025 to May 2026. These were reported as incidents and the senior sonographer reviewed each case and completed clinical supervision to help the individual clinician to understand where errors had occurred. 

Outcomes for women were positive, consistent and met expectations. The service completed 4,495 scans from June 2025 to May 2026. Most scans were successful at first attempt. There was a rescan rate of 5.8% to 12% between June 2025 and May 2026, with a total of 395 rescans over the same period. Staff would try to ensure scans were successful at the planned visit and would ask women to walk around and rescan if an image was not possible. Women could have up to two rescans if the baby’s position did not enable viewing.

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. The service had referred 57 women for an NHS review from January to June 2026, the majority of these were to the Early Pregnancy Assessment Unit.

Improved clinical governance processes supported continuous improvement. Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time. The sonography lead audited the quality of images for all staff and gave advise on how this could be improved during supervision session, if necessary. 

The service did not always tell people about their rights around consent; however, information was shared and understanding checked and consent was always obtained prior to appointments.

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), or 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 stand-alone MCA training and could not clearly explain how they would assess or document a person's capacity to consent. MCA principles were included as learning objectives within mandatory safeguarding adults training. Staff recognised when concerns about capacity should be escalated, their understanding of the legal requirements of the MCA was inconsistent. 

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, and consent confirmed during appointments. Care was taken to ensure information was not shared without the woman’s consent, and where necessary, enquiries were referred back to the woman.

Consent was documented through online consent and waiver forms completed at booking or on the day of the appointment and retained within the patient's record. 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 that all aspects of consent and capacity were managed in line with current legislation and best practice. 

Staff made sure women consented to treatment based on all the information available. We saw that the difference between scans was clearly explained enabling informed choices.