Numi Scan Ltd Also known as Stansted Clinic

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

We looked for evidence of safety for everyone, and whether leaders embedded a culture of openness and collaboration. We checked that service users were safe and protected from avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating remained requires improvement. This meant the previous concerns in relation to safety and quality had not improved.

The service was in breach of legal regulation in relation to the safe and effective staffing of the service and infection prevention and control.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Quality Statement Score: 3

We scored the service as 3. The had been no recorded incidents, however there was a system in place to listen to concerns about safety.

The registered manager had an incident reporting policy and a system in place, such as a logbook, to manage complaints. No complaints or incidents were recorded in the 12 months leading up to the inspection.

The registered manager understood the duty of candour. They understood the need to be open and transparent when things went wrong. There had been no recorded incidents that required duty of candour.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The registered manager did not share discharge records with service users or external providers. Although escalation procedures were in place, these were limited to referring individuals to Accident and Emergency services or their GP. This strategy lacked forward-thinking safety planning and internal protocols, falling short of expected standards for risk management and continuity of care.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always share concerns quickly and appropriately.

The registered manager did not promote a consistently proactive safety culture and provided limited evidence that risk-related learning influenced care delivery.

The registered manager lacked an up-to-date Disclosure and Barring Service (DBS) check and had no system for regular updates, though this was corrected upon request. Regular DBS checks provided essential safeguards when working alone. Particularly when working with pregnant clients and individuals undergoing vascular screening, due to the sensitive nature of these services.

It appeared that the registered manager had limited understanding of the chaperone’s role.
Although a Chaperone Policy was in place, there was no client-facing information available to support its implementation. This lack of visibility may have impacted key safeguarding principles and fell short of regulatory expectations for ensuring patient safety.

However, the registered manager demonstrated compliance with safeguarding training and gave a strong verbal account of their safeguarding knowledge. A safeguarding policy was in place, and they had contact details for the local authority’s safeguarding team.

We work 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.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The registered manager did not consistently engage with individuals to understand and manage risks.

The registered manager did the right safety checks for ultrasound baby scans, but did not do any for vascular screening. Instead, they used an old referral guide from May 2017, which had not been reviewed or updated to meet today’s standards.

The guide advised sending service users to their GP or to AE when problems came up. This advice did not meet the clear rules and steps laid out in the latest 2025 NHS/AAA screening programme and 2024 Vascular Society guidelines. Both highlighted the importance of having detailed decision points and clear routes for follow-up care.

This lack of up-to-date guidance was concerning because staff worked alone, without anyone else on-site to support decision-making. That meant they needed even clearer, more reliable instructions to keep service users safe.

The registered manager told us that they would call emergency services in the event of a service user becoming unwell. There was first aid kit available, and the registered manager was training in basic life support.

The scanning equipment was serviced at regular intervals. The registered manager told us there was no requirement for daily checks or calibration due to the digital nature of the kit.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The registered manager did not always use equipment, rooms or technology in ways that made care safe or met people’s needs.

The equipment available was suitable for its purpose. However, the building was not accessible for service users who used wheelchairs. The registered manager said they would help those with mobility issues manually, but this could affect a person’s dignity, independence and safety.

The registered manager had a fire evacuation plan and explained the steps to follow in an emergency. However, the fire extinguishers were not mounted or marked with dates, which could have put service users at risk.

The registered manager shared a lone working process, which involved passing client details to a trusted contact. However, this person was not always available, making the safety measure unreliable.

We make 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.

We scored the service as 1. The evidence showed significant shortfalls. The registered manager worked alone, and did not make sure they had the most up to date experience and skills. They did receive effective support, supervision and development. They did not work with others to provide safe care that met people's individual needs.

The registered manager could not evidence that their skills and training beyond mandatory training were up to date. The registered managed did not receive effective support, supervision and development.

The registered manager had completed all mandatory training. However, this had been completed following our announcement of our onsite visit. There had been a gap in mandatory training compliance from January to June 2025.

The registered manager could not demonstrate the required competencies as outlined by the Health and Care Professions Council (HCPC). This included gaps in maintaining up-to-date knowledge, engaging in relevant continuing professional development (CPD), and demonstrating how learning benefited service users. Failure to meet these standards may impact on the ability to practise safely and could place HCPC registration at risk.

Clinical practice in vascular screening was infrequent, which raised concerns regarding the maintenance of professional competencies. According to HCPC standards, all registrants must ensure their knowledge and skills remained current to practise safely and effectively. Extended periods of minimal practice without appropriate continuing professional development (CPD) or supervised re-engagement may compromise patient safety and service quality. This could affect fitness to practise.

The registered manager carried out vascular ultrasound screening for clinical significance. For example, arterial stenosis and aneurysms. The 2023 British Medical Ultrasound Society guidance stated this was a specialist field that needed regular Continuing Professional Development (CPD). We did not find evidence to support this guidance. It was essential that this work was supported by clinical knowledge. Vascular sonography, a specialist field demanded not only technical skill but also sound judgement, appropriate escalation, and clear reporting.

The registered manager was unable to evidence any role specific training in relation to vascular screening in line with the National Institute for Health and Care Excellence standards. We escalated this to the provider who has since completed his continuing professional development.

The service governance policy included regular skill sets reviews. However, there was no evidence of recent training or continuing professional development to support this. The registered manager was unable to provide evidence of any further training to evidence a commitment to keeping knowledge and skills. This was particularly important in relation to vascular screening to help keep service users safe.

The registered manager did not receive any external supervision or professional appraisals.

Peer audits had been undertaken. However, these were limited to one peer who was part of the Numi Scan franchise.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading. Although infection prevention and control policies and notices were displayed, they were not consistently followed in practice. This limited assurance of safe hygiene protocols.

The clinic environment appeared clean on the surface. However, a stained rug, dusty areas, dirty sinks and unclean disorganised cupboards were seen. This could pose a risk to infection prevention and control.

The registered manager stored couch rolls (disposable protective paper used to cover examination couches) directly on the floor. This undermined infection prevention and control standards by increasing the risk of environmental contamination.

Hand hygiene audits had been completed with full compliance. However, these were self-assessments rather than peer-reviewed audits. This limited their effectiveness in identifying and addressing practice issues.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

The service did not stock or administer medicines or contrast media for any scanning procedures. These were not required for the type of service offered.