Before the Stork

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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

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

At our last assessment the service was in breach of regulation for fit and proper persons: directors, fit and proper persons employed and staffing. At this assessment we found the breaches had been addressed and the service was no longer in breach of regulation.

The service had made improvements to ensure appropriate checks for directors were completed and staff recruitment and safeguarding training was carried out for staff.

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.

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. 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 people and their communities.

The registered manager had plans to develop the service offered to women in the future and plans were in progress for this.

Staff were proud of the service provided and worked well together. They described a positive family culture and had worked together since 2005.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. 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 registered manager was also one of the directors of the company and held responsibility for regulatory compliance. They had the skills, knowledge and experience to perform their role. They gave examples of leading with integrity and by example.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 3. 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.

Women had the opportunity to give feedback on the service following their scan appointment.

Staff could raise concerns with the registered manager. If they were not happy with the registered manager’s response they could raise concerns externally. We did not see any concerns had been raised by staff on our assessment.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. 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.

Staff were treated fairly and equitably. The registered manager understood the Equality Act and the requirement for reasonable adjustments to support staff wellbeing.

Staff worked flexibly to fit around their personal and professional commitments.

The service had an equality, diversity and inclusion policy. We were given examples of supporting staff for their individual needs.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. 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 held overall responsibility for the governance systems and processes and monitoring performance.

Policies and procedures were in place to support the service. Scan procedures followed best practice and national guidance for women using the service.

Risks were identified and managed to ensure the quality of the service was maintained. We identified one risk that had not been considered by the registered manager in relation to vaccination recommendations for the phlebotomist taking blood samples. This was raised during our assessment for review and consideration.

Systems and processes were in place for managing information. Women using the service completed paper records which were scanned onto the electronic system. Scans were deleted from the system after a set period of time.

Audits included ALARA to ensure the thermal index was in range. The thermal index is an ultrasound safety metric that estimates the potential for tissue heat during a scan. An annual peer review was in place with a competitor to look at images and standards.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. 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 had a clear referral pathway to NHS services for any concerns or anomalies identified. This had been agreed with local NHS maternity services.

The registered manager signposted women when required during the telephone booking assessment to NHS services when indicated.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 3. 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.

The registered manager was passionate about the service delivered and had plans to develop the service. This included online booking for women and additional blood tests to support the needs of women using the service.

The scanning machine had been replaced within the last 12 months using the most recent available technology. An equipment replacement plan was in place for 5 years’ time.