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Inspection carried out on 09 April 2019

During a routine inspection

Pregnancy Advice Salisbury is operated by a registered charity, Foundation for life (Salisbury). The service provides advice and pregnancy ultrasound services to women.

The service provides limited non-diagnostic ultrasound two dimensional scanning as an option for women with unplanned pregnancies, the scan would show movement and image. There is no age restriction and the service will scan children under the age of 18 years.

The primary aim of the service is to allow women who wish it, to visualise their pregnancy and provide clarification of pregnancy dating. The service website states “Pregnancy Advice Salisbury values all human life equally” and descrives their value as “Pregnancy Advice Service (Salisbury) has Christian convictions aiming to show love to all, especially those who are distressed and in difficult circumstances. We are committed to valuing all human life equally and believe that children are a great gift”.

The service is regulated by the Care Quality Commission for the activity of diagnostics and screening, which covers the ultrasound scanning provision of the service. Advice was also provided about pregnancy. We looked at the advice part of the service to gather a wider context and only as part of the pathway to the unltrasound procedure. If patients recieved advice without an ultrasound scan, this did not fall within CQC regulated activity.

The nominated individual described the service as providing support to women to enable them the space to think about their pregnancy and discuss the issues they faced. The staff were all volunteers.

The service is based in a Christian community building and has three separate rooms used only for this purpose. There is another ground floor room if any women had mobility difficulties. There is easy access via public transport and free parking available.

We inspected this service using our comprehensive inspection methodology. We carried out an announced visit to the service on 09 April 2019. We gave staff two weeks’ notice that we were coming to inspect to ensure the availability of the registered manager andservice.

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.

The service was registered with CQC in 2017 but remains in its development infancy. The service had provided pregnancy advice to five women in the last quarter, with only one ultrasound scan being completed. In the previous year only one other scan had been completed. The service has plans for development and has systems and regulatory requirements ready in preparation.

Services we rate

This service had not been previously inspected or rated. We did not have sufficient evidence to rate the service at this time.

The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to safeguard people from abuse and had completed training on how to recognise and report abuse.

The service controlled infection risk well. Staff kept equipment and the premises clean. Staff used control measures to prevent the spread of infection.The service had suitable premises and equipment and looked after them well. The environment promoted the privacy and dignity of women using the service.

The provider had guidance for staff around potential risks. The service worked mostly alone but had systems to refer to other services to benefit women and their families. The service had clear processes and pathways to signpost patients to local NHS providers should the sonographer note any areas of concern.

The service had enough staff with the right qualifications, skills, training and experience to provide ultra sound scans. The registered manager checked staff were competent for their roles. The managers appraised staff’s work performance and held meetings with them to provide support and monitor the effectiveness of the service.

Records were mostly clear, up-to-date and all were stored securely. The service provided information leaflets for women which gave advice on how to keep healthy during pregnancy, information was not provided on termination of pregnacy services.

The service had developed policies and procedures to advise and guide staff. The service had appropriate processes for staff to raise concerns and report incidents.

The service had an office space for staff to have sensitive and potentially distressing conversations with patients. Staff told us they took time to explain the procedure before and during the scan.

The service assured women that their scan images were treated confidentially. The service planned and provided services in a way that met the needs of people accessing theservice.

The service took account of women’s individual needs and delivered care in a way that met these needs. Patients could access the service in a timely way.

A complaints policy was available for staff to follow if needed.

The manager was available and involved in all aspects of the service and was contacted by the advisors and sonographer if needed.

The manager promoted a positive culture creating a sense of common purpose based on shared values. Salisbury Pregnancy Advice had values of honesty, value and loyalty. Staff worked within these values and told us they tried to provide a positive patient experience.

There was a governance framework to support the delivery of quality patient care. The service had a system to identify risks and plan to reduce them.

The service managed and used information to support its activities, using secure electronic systems with security safeguards.

The service had not been provided to sufficient numbers of women to enable the registered manager to monitor the effectiveness of care and treatment and use the findings to improve them. Seven-day services were not provided.

Feedback cards had been designed but had not yet been given to patients to seek their views of the service.

The service planned to engage and seek the views of patients. The infancy of the service meant that learning and improvement were an ongoing process.

However, we also found the following issues that the service provider needs to improve:

The sonographer confirmed a verbal referral process with the acute hospital early pregnancy service to ensure the transference of patients and information. A written service level agreement was required.

Records of calls and advice provided were not all fully completed.

Recruitment checks were not fully completed to ensure patient safety.

The content of staff induction was not recorded to confirm that all areas planned for induction had been completed.

Records planned for retention for ten years should be retained for 25 years.

The provider should provide translation services from an independent source.

The service did not have a female genital mutilation (FGM) policy that provided staff with clear guidance on how to identify and report FGM.

No training had been provided related to complaints management.


Dr. Nigel Acheson

Deputy Chief Inspector of Hospitals