HELLO BABY

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• 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 good. At this assessment the rating has remained good.

The service was well led with clear strategic direction. There was evidence of regular communication, structured governance and a commitment to continuous improvement.

The provider had embedded a system for risk management and audit, and staff were encouraged to raise concerns and contribute to service development.

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.

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 service had a clear vision and effective plans in place to achieve its aims. The registered manager explained how they were working to deliver high quality care.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. They were proud of the service they were delivering which reflected in the feedback from women who had accessed the service.

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 the owner of the business and held overall responsibility for regulatory compliance. The registered manager had a good understanding of the service they managed. They had the skills, knowledge and experience to perform their role, and maintained oversight of the day-to-day running of the service. The registered manager was responsible for the supervision and appraisals of all staff. They were visible and approachable for both the staff and people accessing the service.

The registered manager told us they kept up to date with guidance from BMUS and other relevant professional bodies to ensure care was delivered in line with best practice.

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 they received in a manner that reflected their individual needs. Staff reviewed the feedback and used it to make improvements.

The service had a whistleblowing policy that enabled staff to raise concerns confidentially with the registered manager. Staff could also raise concerns externally if they were not happy with the registered manager’s response. We did not see any concerns raised by the staff on our assessment.

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.

The service consisted of the registered manager and 4 receptionists. The staff worked flexibly to fit around their personal and professional commitments.

The service had an equality, diversity and inclusion policy in place and staff undertook equality and diversity training as part of their mandatory training.

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 processes and quality monitoring. This included the timely investigation of incidents, oversight of learning and improvement actions to all staff, and provided responses to patient complaints. At the time of the inspection, there were no open incident investigations or unresolved complaints, and all previously reported concerns had been reviewed and appropriately closed.

To monitor performance, the service used patient feedback, complaints and audits. Information was accessible to all staff and helped identify areas for improvement to ensure they provided an effective service.

The service had an audit programme which included monthly local audits, annual audits and peer review. This included infection prevention and control, health and safety, record keeping, scan outcomes and use and outcomes when using the referral pathway. The audits were sufficient to provide assurance, and we saw actions were taken when needed.

Women’s papers, electronic records and information were stored safely and securely. All electronic records and systems were password protected. The service was operating in line with the General Data Protection Regulations (GDPR) for managing women’s personal information, records and data management confidentially. We saw evidence of an information governance policy and the registered manager ensured paper and electronic records were destroyed safely when no longer required. The service shredded confidential waste and disposed safely via a contractor.

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 and staff supported women through the referral process to local NHS trusts. The registered manager followed up with women, to check whether they had attended and to identify if any additional support was required. We saw evidence of this in the service audit, where the referral pathway was used for 4 women in the last 12 months. In these cases, the pathway was followed correctly and the referral followed up. The registered manager had a good working relationship with local NHS providers and other similar independent providers. They were able to access support when and if needed.

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 care they delivered. The registered manager held staff meetings to discuss learning, improvement or innovation of the service.

The service encouraged women to use online and social media platforms to provide feedback and share ideas for improvement. The registered manager also researched the market for new ideas focusing on the needs of women using the service.