Life Through The Lens - Stoke Centre

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires improvement. At this assessment, the rating has remained Requires improvement.

Requires improvement - This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

There was no evidence of staff completing fire checks except for smoke alarm checks and there were no risk assessments in relation to control of hazardous substances, there was no mandatory training schedule.

Additionally, there were no cleaning schedules, or records and ultrasound gel was being dispensed into smaller containers from a large one. This presented an infection prevention control risk.

The service was in breach of regulations for safe care and treatment, staffing, and person-centred care.

Staff told us they had a good relationship with the local hospital and how they could call to make a referral. There was a process to refer service users to hospital if an anomaly was found during the ultrasound. Staff communicated with service users so they understood their care and treatment.

Staff were able to give examples of situations when a safeguarding referral would be needed. Patient information around scans and any risk to the babies was available on the Life Through The Lens website. There were processes to refer service users to hospital if an anomaly was found during the ultrasound. Staff communicated with service users so that they understood their care and treatment.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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.

We scored the service as 1. The service did not have processes in place to ensure 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.

The service had no reported incidents. There was an incident reporting policy to promote safety and learning from incidents. However, the policy contained limited information and lacked detail such as who the incident should be reported to, what was classed as an incident, timescales for investigation or who would investigate and feedback any learning. Therefore, we were not assured that incident reporting was embedded.

Staff had not received incident reporting or investigation training; however, they were able to give examples of what type of an incident they would report. Staff told us if there was an incident the accident book would be completed.

Staff did not fully understand the meaning of Duty of Candour but understood the importance of being open and honest.

There were no opportunities provided for all staff to meet with each other or the registered manager to discuss and share any learning.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured.

We scored the service as 1. The evidence showed significant shortfalls. They did not manage or monitor people’s safety.

There was a clinical procedure for patient verification. The policy stated that staff must receive escalation pathway training, however this training was not in place.

The sonographer told us how they do not scan anyone under the age of 16 years. The policy was if under 16 years old presented it required safeguarding escalation. There was nothing in the policy around parental consent. Service users filled in a disclaimer which had their name, address, and date of birth. Staff did not have any specific training from the service re Gillick competence.

Staff told us they had a good relationship with the local hospital and knew how to make a referral.

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.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Managers relied on sonographers having safeguarding training from alternative employment. There had been no oversight of this prior to our inspection. However, staff knew how to make a safeguarding alert.

There was a safeguarding policy with a purpose to safeguard children, young people, and adults at risk. The policy lacked any detail or necessary information such as what constituted a safeguarding concern, links to legislation, or level of safeguarding training staff required. No details were provided of who was the safeguarding lead that was mentioned in the policy or contact numbers of the local authority.

Staff told us they had not had any situations when they had needed to make a safeguarding referral to the local authority but were able to give examples of situations when a safeguarding referral would be needed.

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.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks

There were processes to refer service users to hospital if an anomaly was found during the ultrasound. Staff communicated with service users so that they understood their care and treatment.

Processes were in place to check service users' identification. The sonographer collected the service user and their signed disclaimer sheet and used this to enter the service user’s details directly onto the ultrasound machine.

Patient information around scans, including any potential risk, was available on the Life Through The Lens website. The website also included information on if there was anything that could be done to improve images and at what point to book a 4D scan. Additionally, it explained that scans were not intended to detect abnormalities and that staff would notify the patient if they identified any issues so they could be checked at the local hospital.

There was an escalation and referral policy which detailed examples of situations requiring immediate emergency escalation and when it would be more appropriate to refer to the NHS, the Early Pregnancy Assessment Unit, or a GP. Staff advised service users of the importance of attending any hospital appointments.

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.

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 service operated over one floor. It had a waiting area, reception, and a scanning room. There was a small toilet and storeroom next to the scanning area. The waiting area had 4D portraits on display.

Staff told us service users were told at the time of booking that the service had steps and that it was not wheelchair accessible. There was no information on this on the website. There was no specific car park available for service users.

There was a steep step down to the ultrasound room which could be a potential trip hazard. Staff told service users and their families to watch the step but there were no signs warning people of the risk. There were also no risk assessments in place relating to this potential hazard.

The registered manager had purchased 2 fire extinguishers prior to our inspection. These had been placed in the scanning room and in the reception area. However, the extinguishers did not have expiry dates and were not securely placed in a stand or bracket to ensure they remained upright and to prevent them from being knocked over or damaged. One fire small extinguisher was placed behind a chair so was not clearly visible, the other fire extinguisher in the scanning room was foam and not suitable for electrical equipment fires. We noted the smoke alarms had been checked regularly and recorded.

There was no evidence that any other fire checks or risk assessments were completed regularly except for smoke alarm checks.

There was a fire escape in the ultrasound room, but this was not visible as it was behind a curtain with a small sign on the ceiling. Staff told us how they would lead service users through the fire escape in the event of a fire. The fire assembly point was the opposite side of the building and across the road.

Portable electrical appliances had been tested, and we saw the ultrasound machine had been serviced in June 2025. Staff told us how they had raised the image quality of the scanning machine with the registered manager due to its age and them not being quite as clear as those they were used to in the NHS. There were no plans in place at the time to replace the machine. However, service users did not raise any concerns about the quality of the images with us.

All waste was disposed of as domestic waste. The service did not have any clinical waste bags should they need to dispose of any unexpected waste. However, this had not yet been an issue at the time of inspection.

Cupboards containing cleaning products were locked but there were no control of substances hazardous to health, risk assessments or data sheets.

There were visible damp patches on the ceiling tiles in the waiting area. Staff told us this was because they had previously had a leak in the roof. When they had replaced the tiles, it was still wet, so it had leaked through further. They told us they were in touch with the landlord of the building to rectify this.

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 2. The evidence showed some shortfalls. The service did not always make sure staff received effective support, supervision, and development. They did not always work together well to provide safe care that met people’s individual needs.

The service had 3 sonographers, 2 radiographers and 1 midwife. The sonographers also worked for the NHS.

Staff told us if a sonographer or the receptionist were unavailable the service would reschedule booked appointments.

The service did not use agency staff or bank staff. The day-to-day service ran with one sonographer and the admin/reception staff member.

There were no mandatory training schedules, matrix, expectations, or requirements in place. The service did not provide any mandatory training for the sonographers. The sonographers mandatory training was completed through their roles in their permanent employment within the NHS. The registered manager did not have any oversight in making sure it was up to date.

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 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The receptionist completed all the cleaning within the service, but there were no records to evidence this. No additional deep cleaning within the service had been completed.

We were unable to observe if the sonographer washed their hands between patents as this as there was no sink in the scanning room. We did not observe them using hand gel. The sink was in the separate toilet area.

Ultrasound gel for patient use, was being dispensed from a large container to smaller bottles which posed an infection prevention control risk.

There were wipes available to disinfect probes after the ultrasound scan. We observed paper roll was changed between service users. There was personal protective equipment available in the scanning room.

An Infection Prevention and Control Policy was available with a purpose to prevent and control risk of infection to service users, staff, and visitors. The policy outlined responsibilities of staff, hand hygiene, and cleaning. However, the policy mentioned cleaning schedules must be signed and dated and that all staff must complete yearly infection prevention and hand hygiene training and that these must be available for inspection, which they were not. The policy also mentioned an annual infection control audit, but staff told us that no cleaning audits took place. The service did not provide their own infection prevention and control training but relied on the sonographers training from their other employment.

However, all areas appeared clean and tidy. Service users found the service clean and tidy. There was hand gel available in the patient waiting area.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.