MYM Tamworth

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.

This is the first inspection of this service. We rated this service as good because 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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. 

Staff raised concerns and reported incidents and near misses in line with the service's policy. The service used an online form to record any incidents. These were shared with the local manager for investigation and wider management team for oversight and shared learning.

We saw that there had been 8 incidents reported from December 2025 to June 2026. These included wrong gender identification, a flood and data breach.  Each incident had an associated action plan and lead for actions. Incidents were discussed locally with the team and at group meetings to ensure knowledge and actions were shared.

The service had no never events and no serious incidents in the year preceding the inspection. Never events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

Staff understood the duty of candour. They were open and transparent and gave women and families a full explanation if and when things went wrong. We saw that apologies were made in complaint responses and people were offered the opportunity to seek additional information as necessary. Complaints were prevented where possible at the time. The manager told us care was taken to ensure the team knew how to communicate effectively and recognise when things went wrong. This resulted in a proactive approach to preventing concerns and complaints.

Staff met to discuss the feedback and look at improvements to patient care. We saw that incidents were discussed as part of team meetings which occurred monthly. Staff spoke about sharing learning to improve women’s experiences. Managers investigated incidents thoroughly. Women and their families were involved in these investigations.

There was evidence that changes had been made because of feedback. We saw that following one incident relating to the incorrect scanning images being shared, the computer system was reviewed and controls implemented to prevent reoccurrence.

Managers debriefed and supported staff after any incident or difficult conversation/ appointment. Although there had been no serious incidents, managers told us, de briefing occurred after any difficult appointment, for example when women were informed that their pregnancy was nonviable.  This ensured that staff were supported and provided with relevant feedback for their development and learning.

The service worked with women 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.

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 was 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 that women were encouraged 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.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Most women booked their appointments online or via a call directly to the service. This enabled essential information to be collected ahead of attending the studio.  When repeat scans were planned the service offered additional packages, which enabled women to book appointments to suit their needs or with the same sonographer/ team member.

Staff involved all the necessary healthcare to ensure women had continuity of safe care, both within the service and post-discharge. Women were requested to share details of their chosen NHS trust to enable referrals and ensure any communication was sent to the right location.

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.

Staff could work across all MYM sites. All sites used the same equipment/ policies and processes which meant that staff could move across sites if necessary. 

The service had approached local NHS trusts to introduce their services and reinforce links with maternity services. We were told that some trusts had provided contact numbers and details of services along with preferred method of referrals. This enabled the service to have a robust process for referring women onto teams in the event of an abnormal scan. 

The service worked with women 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.

Staff were trained in safeguarding and knew how to make a safeguarding referral when appropriate. All staff were trained in safeguarding adults and children, with the level of training dependent on the role. Clinical staff were trained to level 3, and administration roles to level 2. Staff had access to a safeguarding lead trained to level 4.

Staff knew how to identify adults and children at risk and worked with other agencies to protect them. Staff spoke openly about referrals to the multiagency safeguarding hub (MASH) and how they were confident in raising concerns about women or children at risk. We saw evidence of referrals and monitoring of outcomes within team meeting minutes.

Staff responsible for answering the phone gave clear descriptions of how they protected women from sharing personal information without consent. For example, staff did not discuss appointment details when calls were made relating to checking appointment details or changing times, to prevent information being shared incorrectly. We were given examples of how ex partners had attended or called the studio and how staff had managed to prevent giving details without consent.

Staff we spoke to recognised signs of abuse and neglect in the context of their role, including signs of domestic abuse. 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.

Staff followed safe procedures for children visiting the service. Children were always accompanied by a responsible adult and staff made sure they were involved with the appointments. We saw how staff spoke to children attending appointment with their parents and involved them with the process, encouraging questions and activities to keep them occupied.

The service did not provide chaperones but supported women to arrange a chaperone if they wanted. 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 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.

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.

Staff completed risk assessments for each woman attending the studio at each visit. Women were required to complete a checklist prior to their appointment. This included checks regarding length of pregnancy, the details of the testing required, emergency contact details and details of the chosen NHS trust for ongoing care. 

Staff knew about and dealt with any specific risk issues. We saw that women were given clear information which included details of any identified issues with the pregnancy. We saw one woman was referred to their host NHS trust following a scan as the sonographer had identified some concerns which required further investigation. Information provided was clear and explained what actions the woman needed to take. 

Staff shared key information to keep women safe when handing over their care to others. When escalation was required for scan anomalies staff knew who to contact and ensured the concerns were effectively communicated. We saw that information was clear and detailed in the preferred format of the receiving NHS trust.

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. 

Staff were familiar with managing an emergency situation. 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.

Clear scanning protocols supported staff to deliver care safely and consistently. Protocols were programmed into the ultrasound machines by the manufacturer.

The manager collected feedback from women and their families about the service and care they had received. The manager was responsible for feedback through social media as well as feedback provided during appointments and retrospectively though complaints. Details of concerns were shared with staff, to share learning and prevent reoccurrence.

Women were able to bring support or advocates to their appointments. There was a limit of six people accompanying women to appointments due to room size.

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 of the environment followed national guidance with handwashing facilities and flooring that was suitable to the needs of the service. The studio consisted of a large reception area, one scanning room, public toilet and storage / staff areas. There was no staff rest area to enable breaks away from the work area. However, break times were protected, with no appointments which meant there were periods with no public on site. 

Equipment and facilities were suitable for their intended purpose and supported the delivery of safe care. All scanners had function limits to non-diagnostic scans preventing measurement and growth scans. 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. We saw equipment was regularly maintained by the manufacturer. 

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. Lighting and viewing arrangements supported a positive experience, and rooms could be secured to ensure privacy.

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.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough sonographers and support staff to keep women safe. There was always a sonographer and admin/ receptionist on duty and a studio manager who worked set days per week. Appointments were usually booked in advance, and staff knew when activity peaked which was usually at weekends and in the evening. 

Operational hours enabled appointments across six days per week, with flexibility to attend appointments between 9am and 8pm. Sonographers worked set days/ hours. The studio was planning to reopen seven days per week pending an appointment of a further administrative role. 

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 low and reducing vacancy rates. Staff told us they worked flexibly, covering leave or sickness as necessary, which meant there was no impact on appointments. The team were in the process of recruiting two new sonographers and had a receptionist/admin vacancy. The gaps created by these vacancies were being covered by allocating additional duties to staff and flexing staffs’ roles. For example, the manager covered receptionist duties when cover was not available. Staff reported that they had been in post for several years, which meant the workforce was largely established and stable.

The service had low rates of bank sonographer usage. Managers used staff who had been previously employed by the service as bank staff. This meant that staff were familiar with the service, policies and processes. All staff, including bank staff completed a role specific induction. 

All staff completed mandatory training in role specific training. We saw that compliance was 100% across all topics except one. We saw that 3 sonographers had no certificate confirming they had completed the National Bereavement Care pathway. However, we felt assured that care was taken to ensure bereavement was managed sensitively. Training compliance reports were generated at the start of each month which enabled managers to identify whose training was due for renewal. MYM Tamworth followed the organisations training programme with most training taking place in September.

Managers invested 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 confirmed competencies had been completed for all staff. Staff carrying out blood tests for NIPT had received competency-based training from an external provider. 

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. 

All new staff completed an induction, which included role specific skills and overview of the organisation. All staff were allocated a 12-week probationary period during which they would develop their skills within the role, and complete necessary training.  Staff told us they worked with senior/ experienced staff and were supported to complete their roles. The probationary period could be extended if necessary. 

The manager provided a trial day for new admin/ reception staff prior to employment, which enabled the individual to confirm that the job was for them. The manager explained that because the role was so varied, and relied upon effective communication with the public, it was essential that new employees understood role requirements prior to committing to the post. This lengthened the recruitment phase, but ensured staff employed were aware of what the job would be like.

There had been multiple changes across the service with a restructuring of managers in the last 6 months. This had generated new roles, and although there was no induction for these roles, staff knew what was expected of them and were being supported to develop skills in line with service needs.

There were no formatted local team meetings, however, because there was a small team and the manager worked with each staff member, meetings were considered unnecessary. Staff spoke openly and felt they could escalate any concerns to the manager. They felt included and informed of plans and changes to the service. MYM provided organisational team updates with newsletters and wider team meetings.

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 generally performed well for cleanliness. We saw infection control and prevention audits which detailed reviews of equipment, single use clinical equipment expiry and the correct storage of chemicals and samples. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. There was a cleaning schedule which included clinical and non-clinical areas.

Clinical areas were clean and had suitable furnishings which were clean and well-maintained. Staff cleaned equipment after patient contact and a cleaning log captured the details daily. Managers reviewed cleaning routines and checked that equipment was suitably clean and ready to use.

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.

People were protected from infection because the environment and equipment were clean, well maintained and suitable for their purpose. Staff followed infection control principles including the use of personal protective equipment (PPE). We saw PPE was readily available and staff used it for all patient contacts. Hand sanitiser was available on entry to the studio, and we saw people used it when entering.

Staff used pre-filled ultrasound gel bottles. They 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 explained precautions taken when women had suspected infections, for example, the use of masks, but confirmed most women did not attend if they were not feeling well, and therefore there was minimal risk/ few occurrences when additional PPE was required.

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.