Cherished Moments

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• 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 people 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. This key question has been rated good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 evidence showed a good standard. 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 women and their communities.

The service had a clear vision centred on providing high-quality, compassionate care for women and their families. Leaders had defined values that focused on kindness, professionalism, safety, and continuous improvement, and staff understood how their individual roles contributed to achieving these aims. We saw these values reflected in the way staff delivered care and interacted with people using the service.

Staff consistently described a positive and supportive culture. They spoke enthusiastically about their work, demonstrated a genuine commitment to providing a positive experience for women and their families, and worked collaboratively to maintain high standards of care. This was reflected in the positive feedback received from women and in the way staff supported one another during our inspection.

Leaders had a good understanding of the service's strengths and areas for development and encouraged a culture of openness and learning. Staff told us they felt comfortable raising concerns, sharing ideas, and contributing to service improvements. They said leaders were approachable, listened to feedback, and valued their contributions.

The service promoted an inclusive and person-centred culture. Staff told us they felt respected and well supported in their roles, and we saw evidence that individual achievements and commitment to delivering excellent care were recognised and celebrated. We saw in team meeting minutes staff were commended on their commitment to excellent client care. Staff also spoke positively about the future of the service and their involvement in planned developments and improvements.

The evidence showed a good standard. 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 led by the registered manager, who was also the provider, and had overall responsibility for the quality, safety, and governance of the service. They maintained oversight of the day-to-day operation of the clinic, including supporting staff through supervision, appraisals, and ongoing performance monitoring.

The registered manager demonstrated a commitment to maintaining high standards by keeping up to date with developments in ultrasound practice and guidance issued by the British Medical Ultrasound Society (BMUS). This helped ensure the service continued to reflect current professional standards and evidence-based practice.

The registered manager was present or easily contactable whenever the clinic was operating, providing visible leadership and day-to-day support for staff. During our inspection, staff described management as approachable, supportive, and readily available to provide advice or assistance. Staff told us they felt comfortable raising concerns or discussing ideas for improvement and were confident these would be listened to and acted upon where appropriate.

The registered manager demonstrated a clear understanding of the service and its priorities. They ensured staff had the appropriate qualifications, training, supervision, and opportunities to maintain and develop their competence. Staff told us they were encouraged to contribute to service development, and we saw evidence that leaders actively sought staff views and supported professional development to improve the quality of care provided.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had an up-to-date whistleblowing policy, outlining when and how staff should or could speak up. The policy recognised that raising concerns about wrongdoings can be one of the most difficult and challenging things to do in a work environment. The policy encouraged staff to come forward with legitimate concerns without fear of being blamed or of any reprisal.

Staff had regular access to the registered manager and were encouraged to discuss any concerns promptly through informal conversations, one-to-one supervision, or team meetings. They told us they felt able to speak openly and were confident their concerns would be listened to and addressed appropriately.

Women and their families were encouraged to share their experiences of the service through feedback and complaints. Systems were in place to receive, review, and respond to feedback. Clear processes were in place to manage feedback and complaints, and staff were encouraged to resolve issues promptly wherever possible.

The evidence showed a good standard. 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.

The service promoted an inclusive working environment where equality, diversity, and respect were embedded in everyday practice. An up-to-date equality and diversity policy set out the provider's commitment to ensuring people and staff were treated fairly and without discrimination. All staff had completed equality and diversity training and understood their responsibilities under the Equality Act 2010.

During our inspection, we observed positive and respectful interactions between members of the team. Staff communicated professionally, supported one another, and demonstrated mutual respect regardless of their role. The leader ensured all staff, irrespective of their role, had access to regular appraisals and opportunities for development.

Clear policies were in place to address bullying, harassment, and discriminatory behaviour, and staff told us they felt confident any inappropriate behaviour would be taken seriously. They described the culture as fair, respectful, and inclusive, where everyone was valued and encouraged to speak up if they had concerns.

We saw staff providing welcoming and personalised care to women and their families from a range of cultural backgrounds, treating each person with dignity and responding to their individual needs.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The registered manager had overall responsibility for overseeing governance arrangements and monitoring the quality of the service. We found evidence of effective oversight through our review of policies, team meeting records, and discussions with staff. Meeting minutes demonstrated that staff were regularly updated on service developments, training, and changes to policies or procedures. Staff understood their individual responsibilities and accountability. Staff had frequent opportunities to come together to share information with each other, review the service's performance, and identify learning and improvement opportunities.

The service had developed policies and procedures for the operation of the service, which were available to staff electronically. All policies were up to date, referenced to relevant professional bodies and reviewed annually.

Patient information was stored safely and securely. The service used paper records to record consent, and bookings were held electronically. Scan images were stored appropriately and ensured information was only accessible by people who worked for the service. We saw a data protection registration certificate issued by the Information Commissioner’s Office (ICO). This demonstrated that the organisation meets its legal responsibilities under the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

The service had a risk register that was reviewed by the registered manager as part of their annual governance review following significant incidents, changes to the service, or where new risks were identified. It included health and safety, information governance, lone working and equipment failure. The risk register detailed the impact, risk level and action to mitigate the risk.

Leaders had oversight of operational performance and quality measures. Performance was reviewed through monthly business reports, governance meetings, feedback, audits and ongoing service monitoring.

Leaders used a structured competency framework to ensure sonographers remained competent and practised within the limits of their professional role. Competence was monitored through regular supervision, peer review, reflective practice, and ongoing assessments to provide assurance that safe and effective standards of practice were maintained. The service swapped scan images with other baby scanning services every 4-6 months to review image quality.

The service had a business continuity and planning policy that set out how a service will continue to operate safely and minimise disruption if an unexpected event affects normal operations. This demonstrated potential risks had been identified and plans were in place to respond to them.

The evidence showed a good standard. 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 collaboratively with another Cherished Moments location to maintain consistent standards and governance arrangements. Staff supported both sites, enabling the sharing of learning, good practice, and operational processes to promote a consistent approach to care delivery across the services.

The service worked with other national baby scanning services to complete image peer review, to improve image quality. We saw collaborative working with local NHS early pregnancy and maternity units, which facilitated responsive referrals when required.

The evidence showed a good standard. 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 supported to have the time to develop their skills around improvement and innovation and to pursue areas of interest in the service. Staff were given time to complete mandatory training and time to develop their practice. For example, the service was supporting a member of staff through registered manager training, with a view to expanding their role. We saw evidence of continued learning and improvement across the service in documented team meeting and governance meeting minutes.

The service had recently introduced early gender blood tests and non-invasive prenatal testing (NIPT). These developments allowed families to access more of their pregnancy care within one trusted and familiar environment. We saw evidence in meeting minutes about increasing services available to people to include antenatal education, baby massage and baby sensory.

The service had started transitioning their governance audit programme to an external compliance platform to support a more structured and sustainable approach to quality assurance.