28 November 2019
During a routine inspection
Lanes Medical Practice accommodates a women’s scan clinic which is operated by Polar Diagnostics LLP under a practising privileges contract. The clinic offers the following scans to self-funding women aged from 18 years, as outpatients’ appointments:
Early pregnancy scans
Dating Scans
NIPT (a non-invasive prenatal test)
Gender scans
Growth Scans
Foetal wellbeing scans to include 3D or 4 D images.
Pelvic scans
Fertility related scans for follicle tracking or endometrial thickness
The clinic is registered to provide the regulated activity of diagnostic and screening procedures.
The clinic has a CQC registered manager who is a sonographer and another part time sonographer who is also employed at a local NHS trust.
The scanning facility occupies a single room at Lanes Medical Practice and shares their waiting area, the receptionist, kitchen, toilets and some office space.
We inspected the scanning service using our comprehensive inspection methodology. We carried out a short-notice announced inspection on 28 November 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.
This clinic had not previously been inspected or rated using the current methodology.
We rated it as Requires improvement overall because:
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The clinic’s safeguarding adult procedure did not reflect up to date guidance in relation to safeguarding adults. The provider did not have a policy in place to safeguard children. There was no formal process to manage safety incidents and learn lessons from them.
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There was no process to ensure staff were registered to practice or that they had completed mandatory training, or that the appropriate pre-employment checks were undertaken.
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The clinic had no overarching governance process or system to identify and mitigate risk, or improve quality and performance. There was no vision and values document to ensure staff were clear about the direction of the clinic or personal accountability for the quality of service.
However, we found that:
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The clinic had enough staff to care for women and keep them safe, and controlled infection risk well. Staff were able to respond quickly if women became unwell, to keep them safe.
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Staff worked well together for the benefit of women and supported them to make decisions about their care. Staff audited practice and maintained their skills and competence to provide quality care. The clinic was available for appointments six days per week.
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Staff respected women’s privacy and dignity and took account of their individual needs, helping them to understand their conditions. They provided emotional support to women, families and carers.
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The clinic planned care to meet the needs of local women, took account of women’s individual needs, and made it easy for people to give feedback. Women could access the clinic when they needed it and did not have to wait too long for their scans.
Nigel Acheson
Deputy Chief Inspector of Hospitals (London and South)