Cherished Moments

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

This means we looked for evidence that people were protected from abuse and avoidable harm. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration

This is the first assessment for this service. This key question has been rated good. This meant people 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.

The registered manager demonstrated a clear knowledge of reporting, investigating, and the process of sharing incidents with staff, and understood their responsibility to report any notifiable incidents. We saw evidence of incidents, concerns and complaints discussed and recorded during team meetings. There was an up-to-date accident and incident policy, which reflected national guidance. The policy outlined details of reportable events with a clear process for review.

From November 2025 to June 2026 the service reported no safety incidents or never events. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed.

Staff identified and reported risks which led to service improvements. For example, following a scan where the client had felt reduced movements, the service displayed posters reminding clients to contact their healthcare provider when baby movements were reduced.

The service had a duty of candour policy, staff understood this and followed processes. We saw a letter template used to respond to clients, which showed how the service would be open and honest, give a full explanation, and included feedback from any investigations undertaken.

Staff received feedback from investigations through team and 1:1 meetings.

The service worked with people 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.

The service had clear systems and pathways in place to support women throughout their care. Client consent forms, waiver documentation and information provided by the sonographer made it clear that scans undertaken by the service were additional to those provided as part of the NHS maternity pathway and did not replace routine NHS care. We saw evidence that the sonographer checked women’s understanding of this before proceeding with the scan.

The service had defined eligibility criteria which were screened by both the receptionist and sonographer before appointments were confirmed. Screening included consideration of age, gestational age, pregnancy history and current pregnancy health, to ensure scans were appropriate. We reviewed completed records that evidenced these checks.

The service had a clear referral pathway in place for women requiring further assessment following the identification of a potential anomaly during a pregnancy scan. Staff were knowledgeable about the referral process and had established links with local Early Pregnancy Assessment Units (EPAUs) to support timely access to care. Women were advised to contact their local NHS early pregnancy unit or hospital and were provided with a scan report outlining the sonographer’s findings. Where consent had been given, staff supported women by contacting the relevant NHS service or arranging appointments on their behalf. We saw evidence of referrals being made and follow-up contact from the sonographer to confirm women had accessed the recommended care.

Arrangements for blood testing were safe and well managed. The service had an established contract with an external laboratory provider for the analysis of blood samples. Equipment was securely stored, appropriately labelled and tracked to ensure safe handling and timely processing. Staff followed robust processes for sample collection and transportation, which supported the integrity of samples and timely reporting of results.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on 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 received safeguarding training appropriate to their roles and responsibilities. Reception staff had completed Level 2 safeguarding adults and children training, while sonographers had completed Level 3 training. The registered manager had undertaken designated safeguarding lead training and had included Level 4 safeguarding training within their ongoing development programme.

The service had up-to-date safeguarding adults and children policies in place, which reflected national guidance, and included relevant local authority safeguarding contact details, to support timely referrals and escalation where required. Staff were able to identify the safeguarding lead and clearly described the actions they would take if they had concerns about the safety or welfare of an adult or child. Their responses were consistent with the service's safeguarding policies and procedures.

Staff had also completed additional training in specific safeguarding risks, including female genital mutilation (FGM), forced marriage, honour-based abuse, Prevent, and radicalisation. Information about domestic abuse support services and helplines was displayed within the service to promote awareness and access to specialist support.

The service had a chaperone policy which provided a clear and consistent framework for the use of chaperones during examinations. This helped to protect patients, preserve dignity and privacy, and safeguard both patients and staff.

The service worked with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

The service involved women in managing risks associated with their care by gathering key health and pregnancy information during the booking process to determine whether a scan was appropriate and could be carried out safely.

As part of the consent process, women were asked to provide information about their pregnancy status, recent imaging, maternity care provider and relevant medical history. This was completed on arrival at the service. This enabled staff to identify any potential risks or contraindications and discuss these with women before their scan. Where concerns were identified, staff ensured women had the information needed to make an informed decision about proceeding with the scan.

The service had comprehensive ultrasound examination policies and procedures in place, and staff demonstrated a clear understanding of these requirements. The scanning policy referenced guidance from the British Medical Ultrasound Society (BMUS) and the Society and College of Radiographers (SCoR), helping to ensure scanning practices were consistent with national safety guidance. During the inspection, we observed a sonographer explain that assessing amniotic fluid levels was outside the scope of the service and advised the client to discuss any concerns with their midwife. This demonstrated staff understood the limitations of the service and appropriately signposted women to NHS care when required.

Staff followed established scanning protocols for each type of examination and stage of pregnancy. The parameters were predetermined by the ultrasound equipment manufacturer and were not altered by staff. This helped to ensure scans were undertaken appropriately and consistently according to gestational age. The service adhered to BMUS As Low As Reasonably Practicable (ALARP) principles, this meant sonographers used the lowest possible ultrasound output and the shortest scan duration necessary to achieve the required imaging.

Staff were trained to respond to medical emergencies and demonstrated a good understanding of the service's emergency procedures. All staff had completed emergency first aid at work training and were aware they should call emergency services if required. A first aid kit was available, which we saw was well maintained, regularly checked, and within expiry dates.

Staff responded promptly when women required additional support or urgent referral. The service had clear guidance for managing unexpected findings identified during scans. Staff were able to describe occasions where women experiencing symptoms such as pain or bleeding had been advised to seek immediate assessment from local NHS services. Women could choose whether the service made a referral to an Early Pregnancy Assessment Unit (EPAU) on their behalf or whether they preferred to contact the service themselves. This approach supported women to access appropriate care in a timely manner. Staff told us they routinely followed up women who had been referred to confirm they had accessed NHS services. We saw evidence of referrals and documented follow-up contact.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment and made sure that the equipment, facilities and technology supported the delivery of safe care.

The service maintained a clean, safe and suitable environment which met people’s needs. The service was located on the ground floor and was accessible to wheelchair users and people attending with pushchairs. Facilities included a reception and waiting area, scanning room, blood-taking room, storage area and toilet facilities. The scanning room was designed to support both safety and comfort. It contained a height-adjustable couch, seating for accompanying relatives or friends, and blinds to maintain privacy during examinations. A large wall-mounted monitor enabled those present to view ultrasound images during the scan.

Scanning equipment was visibly clean and had been serviced in accordance with manufacturer guidance. Staff told us they were able to escalate any concerns promptly and described the scanner maintenance team as accessible and responsive. Staff carried out daily quality assurance checks on the ultrasound equipment in line with recommendations from the manufacturer and British Medical Ultrasound Society (BMUS).

Staff managed waste safely and in line with relevant guidance. Offensive waste and clinical waste were segregated appropriately, and sharps bins were available for the safe disposal of equipment used during blood sampling procedures. The service had arrangements in place with an external contractor for the collection and disposal of sharps and clinical waste. Substances subject to the Control of Substances Hazardous to Health (COSHH) Regulations were stored securely in a locked cupboard.

Fire and electrical safety arrangements were well managed. Staff had completed fire safety training, and records demonstrated that fire safety equipment and electrical systems had received the required inspections and testing. Fire safety equipment was clearly visible and well maintained, evacuation assembly points were clearly displayed, and fire exits were unobstructed and easily accessible.

The evidence showed a good standard. The service made sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

The service had robust recruitment processes in place to ensure staff were suitable, competent and safe to work with people using the service. A detailed recruitment policy outlined the required pre-employment checks, including references, identity verification and Disclosure and Barring Service (DBS) checks. The policy emphasised fairness, transparency and safety throughout the recruitment process. We reviewed staff records and saw evidence of completed enhanced DBS checks, qualifications and training certificates.

The service employed two sonographers. One held a postgraduate certificate in medical ultrasound and the other had completed specialist ultrasound training. Although this training was not accredited by the Consortium for the Accreditation of Sonographic Education (CASE), we saw evidence that the programme covered competencies aligned with the Society of Radiographers' Competencies for Ultrasound Practice in Private Baby Scan Clinics (2022).

Staff received appropriate mandatory, role-specific and continuing professional development training to support them in their roles. Training records demonstrated staff were up to date with required training, including disability awareness, autism awareness and supporting people with anxiety. The registered manager maintained an effective training matrix to monitor compliance and ensure training was completed within required timescales.

Managers monitored mandatory training and reminded staff when updates were due. Training compliance was 100%. We saw evidence that all newly appointed staff completed an induction programme which included mandatory training.

Staff undertaking blood tests for early gender testing and Non-Invasive Prenatal Testing (NIPT) completed competency-based training provided by an external organisation. We saw evidence of competency assessments, which included supervised practice and ongoing evaluation. This demonstrated staff had the skills and knowledge required to perform these procedures safely.

The service supported ongoing professional development and competence. Records showed staff received annual appraisals and participated in yearly peer-to-peer observational competency assessments. These assessments provided assurance that scanning practices remained safe and effective, promoted consistency in the quality of examinations, and helped identify additional learning and development needs.

Staffing levels were sufficient to support safe service delivery. The service did not rely on bank staff and had arrangements in place to ensure staff did not work alone. Managerial support was available throughout operating hours and ensured staffing was managed effectively.

Sickness absence was low, and staff told us there were enough colleagues available to meet the needs of women and their families while allowing staff to take appropriate breaks during their shifts. Staff said that if there was short-notice sickness absence, they could cover this by calling in another member of staff where available. If staffing levels could not be maintained, appointments could be moved to the provider's alternative location or rescheduled to another day to ensure women continued to receive their booked scan.

The evidence showed a good standard. 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.

Staff followed infection control policies which covered key areas including hand hygiene, uniform requirements, cleaning schedules, the management of infectious diseases, equipment decontamination and waste disposal. The policies reflected current national guidance and included arrangements for monitoring compliance through infection prevention and control audits.

Staff completed regular cleaning schedules, and records demonstrated cleaning activities were documented appropriately. Equipment and furniture were in good condition and visibly clean.

Staff adhered to good hand hygiene practices. We observed staff being bare below the elbows and cleaning their hands using soap and water or alcohol hand gel before and after each scan. Appropriate personal protective equipment (PPE), including latex-free gloves and antiseptic wipes, were readily available and used when required.

Ultrasound equipment was cleaned and disinfected between each patient in accordance with established decontamination procedures using approved medical-grade disinfectant between each client. This included the ultrasound machine, transducers and examination couch. During the inspection, we observed staff covering the examination couch with disposable paper roll, which was replaced after each patient. The couch was cleaned between appointments before a new covering was applied.

The service used single-use, non-refillable ultrasound gel bottles supplied by the manufacturer. Bottles were within their expiry dates and were clearly labelled with the date they were opened, in line with recommended infection prevention and control guidance.

Staff managed waste safely and appropriately. Clinical waste, offensive waste and sharps were segregated and disposed of in a manner that protected people from harm and reduced the risk of infection. The service had an arrangement with an external contractor for the collection and disposal of waste from an external clinical waste bin.

Equipment was available to support the management of accidents and contamination incidents. A spill kit was readily accessible, and records showed that the contents were regularly checked and remained within their expiry dates. This ensured staff could respond appropriately to incidents involving blood, bodily fluids or other potentially hazardous substances.

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.