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Inspection Summary


Overall summary & rating

Good

Updated 21 March 2019

Churchtown is operated by Bump of Churchtown Ltd. The service provides ultrasound scans for self-paying pregnant women including gender scans or three-dimensional and four-dimensional scans of their baby.

We inspected this service using our comprehensive inspection methodology. We carried out the short-announced inspection on 23 January 2019.

To get to the heart of patients’ 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.

Services we rate

We rated it as Good overall because:

  • Staff completed mandatory training appropriate for their roles.
  • Staff understood how to recognise a safeguarding concern and how to signpost to other agencies.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises and equipment and looked after them well. The scan machine was serviced annually.
  • Staff knew how to escalate concerns about women and signposted them appropriately to their booked NHS trust hospital.

  • The service provided care and treatment based on national guidance. Audits had been completed to monitor outcomes for women.
  • The service understood how to assess whether a woman had the capacity to consent to the scan and would not scan if the woman lacked capacity.
  • The service cared for women with compassion. Feedback from women confirmed that they were treated well and with kindness.
  • We observed positive interactions between staff and families.
  • The service provided self-pay care in a way that met the needs of local women. Some individual patient needs could be met, such as visual impairment. Women could access the service when they needed it.
  • The service had a “philosophy” that was displayed on the website and had a strategy for the future. There was an open culture and the manager strived to make continuous improvements.
  • The service managed and used information well to support all its activities, using secure electronic systems.
  • The service was committed to improving services by promoting training, innovation with plans to expand the service.

However;

  • Not every woman was able to use the service, such as if not able to understand English.
  • The service had a system to identify risks, however; the document seen on inspection, had not been fully completed, with no dates for review.
  • The service had policies in place, however; these were not dated, including no dates for review, and not all were referenced to good practice or national guidelines.

Following this inspection, we told the provider that it that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 21 March 2019

We rated it as Good because:

  • Staff had completed mandatory training appropriate for their roles.
  • Staff understood how to protect patients from abuse and the service signposted to other agencies in the event of a concern. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises and equipment and looked after them well. The scan machine was serviced as part of an annual contract.
  • Staff knew how to escalate concerns about women and signposted them appropriately to their booked NHS hospital trust or GP.
  • Staff kept records of women’s attendance in secure password protected electronic systems that included the scan machine.
  • The service managed patient safety incidents well. The sonographer recognised incidents and reported them appropriately.

Effective

Not sufficient evidence to rate

Updated 21 March 2019

  • The service provided care and treatment based on national guidance.
  • The service completed audits to monitor outcomes for women and used the findings to improve care at the service.
  • The owner, who was the registered manager, was a practising qualified diagnostic radiographer with a post graduate qualification in sonography.
  • The service was available Tuesdays to Saturdays with evening appointments on Wednesdays.
  • The service understood how to assess whether a woman had the capacity to consent to the scan and would not scan if the woman lacked capacity.

Caring

Good

Updated 21 March 2019

We rated it as Good because:

  • The sonographer cared for women with compassion. Feedback from women confirmed that they were treated well and with kindness.
  • Emotional support was provided to women and their families to minimise their distress in the event of bad news.
  • The sonographer involved those close to women during the scan and any other care.

Responsive

Good

Updated 21 March 2019

We rated it as Good because:

  • The service provided self-pay care in a way that met the needs of local women.
  • Some individual patient needs could be met, such as visual impairment.
  • Women could access the service when they needed it. There was no waiting times and appointments could be made flexibly for families.
  • The service encouraged women to provide feedback about the service and had not received any complaints.

However

  • There was no information in formats other than standard English or an interpreter service. There was no access for wheelchairs.

Well-led

Good

Updated 21 March 2019

We rated it as Good because:

  • The service had a “philosophy” that was displayed on the website and had plans for the future.
  • There was an open culture and the manager strived to make continuous improvements.
  • The service had a governance framework that included recruitment checks for additional staff.
  • The service managed and used information well to support its activities, using secure electronic systems.
  • The service engaged well with women to plan and manage the service, and contacted other organisations appropriately.
  • The service was committed to improving services by promoting training and innovation and had plans to expand the service.

However

  • The service had a system to identify risks, however; they had not been fully completed, with no dates for review.
  • The service had policies, however; these were not dated, including no dates for review, and were not always referenced.
Checks on specific services

Diagnostic imaging

Good

Updated 21 March 2019

Bump of Churchtown provides ultrasound scans for self-paying pregnant women. Diagnostic imaging was the only core service provided at this service. In the twelve months prior to inspection, there were 1,301 scans carried out. We rated safe, caring, responsive and well-led as good. We did not rate effective because we do not have enough information to make a judgement. Staff had completed mandatory training and had the skills to carry out their roles. Care was delivered in line with national guidance and any concern was shared with ta local NHS service. Women were positive about care provided. There were plans to expand the service.