Archived: Bradley Street

Bradley Street (the clinic location) is operated by Betsy Blossom Limited T/A Lollipop 4D Baby Scans. The clinic provides self-referred, privately funded pregnancy scans in 2D, 3D and 4D, including early reassurance scans, genders scans and baby bonding scans. The service provides keepsake pictures and DVDs to people who used the service as well as keepsakes such as heartbeat bears and gender reveal balloons and cannons.

The clinic is based in Manchester city centre in the Northern Quarter.

The clinic employs a manager who is also an ultrasound technician, two receptionists and a sonographer who is able to carry out early reassurance scans as well as gender identification and bonding scans.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 27 and 28 February 2019. The inspection was unannounced.

To get to the heart of peoples’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this provider was baby keepsake scanning.

Services we rate

This is the first time that we have rated this service. We rated it as Requires improvement overall because:

• We were not assured that the service provided mandatory training in key skills to all staff and made sure that everyone completed it.

• Staff had received training on how to recognise and report abuse, but we were not assured that there were effective systems and processes in place to support them to apply it. The safeguarding policy was lacking in detail that would enable staff to know what types of abuse should be reported, how to report it and who to.

• The service did not assess and respond to patient risk well and did not inform women of guidance relating to the risks of souvenir scans. The provider’s consent form did not reference national guidelines that would allow women to make an informed decision about undergoing non-medical souvenir scans and women were not given any informative information to take away with them. The service acceptance criteria did not define women who should be excluded from receiving a scan.

• There was no mention of duty of candour in the incident reporting policy and we could not be assured that there was a full understanding of when it must be applied.

• We could not be assured that incidents were being recorded appropriately. During the inspection, one of the team was involved in an incident with an unsafe chair and this was not reported in the accident book or recorded as an incident.

• The service did not ensure that all staff remained competent for their roles by maintaining up to date employee records.

• There was no routine contact with GPs or acute trusts as part of the woman’s care when possible anomalies or concerns were detected.

• Staff had not received training in the Mental Capacity Act to deal with people who lacked mental capacity.

• Information was not provided in a range of accessible formats in line with accessible information standards.

• The service did not routinely take account of people’s individual needs.

• We could not be assured that people who used the service knew how to make a complaint as there was no information in the clinic about this and the policy was not on the website at the time of our inspection.

• The CQC registered manager monitored customer feedback and carried out audits.

• The service did not have systems or procedures in place to ensure that its policies were up to date, regularly reviewed and referenced current guidelines.

• There was a risk that the clinic was keeping patient information longer than necessary.

However:

• The service controlled infection risk and kept equipment and the premises clean.

• The service had suitable premises and equipment and mainly looked after them well.

• Staff kept records of patient care and these were kept securely.

• Managers monitored the effectiveness of care and used the findings to improve them.

• Staff cared for people who used the service with compassion. Feedback from people who used the service confirmed that staff treated them well and with kindness.

• We saw that staff provided emotional support to people who used the service to minimise their distress.

• Staff involved people who used the service and those close to them in decisions about their care.

• The service planned and provided services in a way that met the needs of local people.

• People could access the service when they needed it.

• The clinic had a vision for what it wanted to achieve.

• Managers promoted a positive culture that supported and valued staff.

• The service had systems in place to identify risks and coping with both the expected and unexpected.

• The service collected, analysed and used information to support its activities.

• The service engaged well with people who used the service and staff to plan and manage the service and collaborated with partner organisations. Customer satisfaction remained high.

• The clinic used customer feedback to improve the service and introduced new keepsakes or gender reveal ideas as they came onto the market.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices. Details are at the end of the report.

Ann Ford

Interim Deputy Chief Inspector of Hospitals (North)