MYM Tamworth

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. 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 people and their communities.

Leadership had changed within the six months preceding the inspection. Roles had been introduced with an operations manager and a sonography lead which split clinical from non-clinical responsibilities. Staff felt that had been an improvement and would enable service development. There was a clear vision for the service, which was echoed by staff locally. All staff shared the vision for providing a memorable and family focused scanning experience, in a welcoming environment. 

Each studio had a designated manager, who was supported by admin/ reception staff and sonographers. Head office managed functionality such as human resources, recruitment, training monitoring and audit oversight. 

Staff reported the leadership culture was inclusive and they felt valued and respected. Staff described the morale as improved since the structure changes, with an increased passion for developing the service. 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 were focused on the needs of women receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where women, their families and carers as well as staff could raise concerns without fear. 

Leaders had a good understanding of the service’s performance and were focused on continuous improvement. All staff were dedicated to improving the service and felt encouraged to offer ideas for service developments locally or across the organisation.

Individual and team contributions were recognised and celebrated, helping to maintain staff engagement, motivation and a shared commitment to delivering high-quality care. We heard that the managers had introduced a reward programme for staff regarding rebooking of appointments. This was across all studios and encouraged the team to book scans for women whilst they were attending for an appointment, rather than booking them online. The MYM Tamworth team had led the rebooking each month and reported a healthy competition across studios.

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

The service was going through a change in management structure and oversight at the time of inspection. The service was led by a managing director who had oversight of the organisation and monitored activity and performance. They were supported by an operations manager and a clinical lead sonographer. This was a new structure which enabled focus on clinical and non-clinical aspects of the service. Locally, there was a studio manager, who was supported by administrative and sonography staff. The MYM Tamworth manager was planning to move into deputy operations manager role once recruitment had been completed for their current post. Although these roles were new to the organisation, the individuals had worked for MYM for several years and had good knowledge of the service.

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. Those staff new to post were positive about the support they were receiving and the encouragement for service development ideas. Staff told us leads were visible across all studios and contactable anytime and a management rota was displayed so staff knew who to contact for advice and support.

Staff demonstrated a flexibility and adaptability and would go above and beyond their role for the benefits of the service. This included working flexibly, outside their planned hours or roles, providing additional on call and filling gaps in rotas as necessary. All stated they were flexible because they enjoyed their jobs and wanted to make sure women received the best possible standards of care.

The local manager led by example and was keen to ensure that all staff shared the same skills and compassion, which was promoted by training, supervision and a trial period to ensure staff demonstrated the skills needed to ensure a positive experience. Staff spoke positively about the local manager and felt they were visible and approachable to staff and women. Staff felt supported and encouraged by the local manager and enjoyed working with them. 

The local manager was responsible for managing social media comments and spent time liaising with head office about responses. This role covered all MYM studios. 

The leadership team met regularly to discuss performance, and any pressing issues. Leads took concerns seriously and knew how to deal with them when raised which promoted a positive culture in the service. 

There were contingency plans in place to ensure the service could continue in the event of an emergency. There was a business continuity plan which detailed actions and leads in the event of service disruption. Staff reported that this had been tested in December 2025 when the building became flooded and the service was unable to run for several weeks.

The service promoted an open and transparent culture where staff felt able to raise concerns and share ideas. Staff were positive about sharing ideas and felt they would be listened to. A whistleblowing policy provided clear routes for confidential reporting. Staff could access an independent senior leader and external organisations for support if necessary. 

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, and leaders investigated concerns sensitively, maintaining 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. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. Staff told us they had opportunities to apply for new roles and complete additional training for development. Staff with protected characteristics generally felt positive about working within the service and felt supported.

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 they had supported with adjustments for personal reasons. Managers understood where reasonable adjustments or flexibility may be needed, for example, to support return to work following prolonged sickness, or staff with a disability.

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 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. 

Appraisals were used to identify any learning objectives and where possible, plans were put into action to develop roles and responsibilities. Staff were encouraged to develop skills and change roles within the organisation. Several of the team had initially been employed into one role, and then developed into manager, or sonography roles. Staff felt supported and encouraged. 

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Following a recent inspection at a sister site, non-clinical policies and governance frameworks had been reviewed and action taken to update where necessary. For example, we saw that the policy for recruitment, disclosure and barring service (DBS), safeguarding and confidentiality policies had been updated and action taken to review all staff files. There had been three gaps in 3 personnel files which was being actioned to ensure they reflected best practice. All clinical policies were aligned to most up to date guidance. There was a process in place to ensure policy sign off which ensured that all policies were review in a timely manner.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, which 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 a clinic rooms.

The governance structure enabled effective 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. There were quarterly senior management and monthly local management meetings. These meetings fed into service level team discussions. 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 there was an audit programme, which focused on clinical safety and performance indicators supported service oversight and continuous improvement.

Leaders had oversight of operational performance and quality measures through a performance dashboard. Data was analysed to determine access to the service and specific scans, quality performance including rescan rates and incorrect gender, complaint overview and financial projections. 

Risks were clearly identified and a formal log used to keep oversight and manage mitigations and/or bring to resolution. The risk register was reviewed regularly by managers, and 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. Each risk had an allocated lead who led on any activities to mitigate risks identified.

Managers understood their regulatory responsibilities. The current 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 registered managers role. Local leaders maintained effective operational oversight and understood regulatory responsibilities.

Managers implemented a competency assessment framework for sonographers which provided assurance that they were working within their scope of practice. In addition, sonographers received regular supervision, and scans were audited/ monitored weekly. There were processes in place to share learning from incidents and complaints, at both senior leadership and service level. 

The service had a business continuity plan which would help support staff with any unexpected events and we were given an example of when the service at MYM Tamworth had been interrupted by flooding. The service also 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 people. They share information and learning with partners and collaborate for improvement.

The service worked closely with the neighbouring NHS trusts maternity and Early Pregnancy Assessment Units to promote a seamless service for women.  The team had contacted key people and units to ensure the referral process was appropriate and that information could be safely shared.

The team worked cohesively across all MYM studios, ensuring effective communication and shared learning. The operations manager and sonography lead worked across all sites, whilst the local manager had additional responsibilities for the Coventry site. This promoted effective sharing of information and partnership working.  This was evidenced when MYM Tamworth had closed unexpectedly due to flooding and the service moved temporarily to the Coventry site.

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

Staff were committed to continually learning and improving services and felt encouraged by the changes to structure and management. Managers and staff had a vision for improvements and 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 locally and 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 were supported to have the time to develop their skills and the service leads promoted innovation, encouraging development in areas of interest. Staff were given time to complete mandatory training and time to develop their practice. For example, an admin staff member had trained to become a sonographer and was encouraged to develop additional clinical skills such as phlebotomy. All new staff were given on the job training in line with the competency assessment.