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Baby Scan Studio Ashford Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 November 2019

Baby Scan Studio Ashford is operated by Baby Scan Studio Limited. The service provides pregnancy keepsake scans to self-funding women, aged from 17 years, in Ashford and the surrounding areas. The scans are abdominal and include 2D, 3D and 4D keepsake and gender scans.

The service is registered to provide the regulated activity of diagnostic and screening procedures.

The clinic has a registered manager and three sonographers who carry out early reassurance scans as well as gender identification and bonding scans. The registered manager also works as the scanning assistant and receptionist.

We inspected this service using our comprehensive inspection methodology. We carried out a short-notice announced inspection on the 10 and 12 September 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.

Services we rate

This service had not previously been rated using the current methodology. We rated it as Requires improvement overall because:

  • The service did not provide mandatory training for staff and there was no ongoing inhouse training for fire safety, manual handling or health and safety.

  • The safeguarding adult and children’s policy was only reviewed five yearly and we found links to current local safeguarding services were out of date, no longer available and did not reference the most recent guidance.

  • The service did not follow a clear process to ensure all staff had pre-employment checks before working with the service. The registered manager did not request references or apply for disclosure and barring service (DBS) checks prior to staff working there. However, the registered manager had applied for DBS checks for all staff that were relevant to the service and we saw evidence of certificates. Prior to our inspection, the registered manager contacted the sonographer’s main place of work and requested employee references.

  • A risk management policy was in place. However, we found the information minimal and did not detail how a risk should be reported by staff. Staff told us they would report any risks to the registered manager but was not aware of how to document a risk. Risk assessments did not give clear guidance on the type of risk, there was no description of the risk and no documentation to show how the service reduced risks. Risk assessments were not always reviewed, documentation was at times unreadable and written in pencil. Written records are a legal document and therefore should be written in ink so as transparent and legible.

  • We found policies and protocols were written by an external company and did not have a clinical oversight of the service. This meant policies did not always relate specifically to the service. For example, the complaints policy mentioned a clinic not related to the service. We found the service did not have systems or procedures in place to ensure policies were regularly reviewed or referenced current guidelines.

  • The service did not have a policy which referred to the Mental Capacity Act, 2005 and there was no service specific training on mental capacity. The register manager had not received mental capacity training. However, sonographers told us they had completed mental capacity training within their other employment.

However, we found that:

  • Staff cared for women who used the service with compassion. Feedback from women told us that staff treated them with kindness and patience.

  • Staff spoke with women in a sensitive and calming manner. Staff provided a warm and relaxing environment for women, relaxing music and appropriate lighting for ultrasound scans. We reviewed comments from women who used the service, which indicated they felt comfortable and calm throughout their scan.

  • Staff provided reassurance and support for anxious women during their first scan appointments. We saw staff speak calmly and in a reassuring manner throughout scans.

  • The clinic gave women enough time during scan appointments and feedback from service users was that they did not feel rushed during their scan. We observed four women attending clinic and they were not rushed during or after their appointments.

  • The service did not have a waiting list for ultrasound appointments. Women were offered appointments for the same week they asked for one. The registered manager told us they were flexible with appointments and tried to accommodate appointment requests.

  • The service had comment cards for service user feedback, which women and their families were asked to complete. Women were also able to leave reviews of the service on the website and social media pages.

  • We observed the registered manager engage positively with service users and staff. Staff we spoke to told us the registered manager was supportive and we observed good working relationships between manager and staff.

Following this inspection, we told the provider that it must take actions to comply with regulations and it should make improvements to help the service to improve. We issued the provider with two requirement notices. The details are at the end of the report.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Inspection areas

Safe

Requires improvement

Updated 22 November 2019

We rated it as Requires improvement because:

  • We were not assured that there were effective systems and processes in place to support staff in identifying safeguarding concerns.

  • The service did not respond to risks well and did not highlight risk assessments clearly.

  • The service did not provide local training for staff.

However:

  • The service-controlled infection risk and kept premises and equipment clean.

  • The clinic had enough staff to provide the right care and treatment.

  • Staff kept patient records within lockable cupboards.

Effective

Not sufficient evidence to rate

Updated 22 November 2019

We did not rate effective. However, we found:

  • Policies did not reflect national guidance and were not specific to the service.

  • Pre-employment checks were not in place prior to staff working with the service.

  • The service did not have a written care pathway for staff to follow when referring women to maternity NHS services when finding an irregularity or health concern.

  • The service did not have a Mental Capacity Act policy and the registered manager had not received specific training.

However:

  • Service user’s views on the service was monitored through feedback cards and social media.

  • The service provided clear verbal and written information to women before and during scans, that the service was not a substitute for antenatal care provided by the NHS. Women were advised to attend all NHS antenatal appointments.

Caring

Good

Updated 22 November 2019

We rated it as Good because:

  • Staff put women at ease, they introduced themselves, explained their role and what to expect from the ultrasound scan.

  • We saw staff provided reassurance and support for anxious women during their first scan appointments.

Responsive

Good

Updated 22 November 2019

We rated it as Requires improvement because:

  • The service did not have a waiting list for ultrasound appointments. Women were offered appointments for the same week they booked.

  • Staff provided a warm and relaxing environment for women, with relaxing music and the best lighting for ultrasound scans.

However:

  • The clinic did not have access to an interpreting service for women who did not have English as their first language or who were deaf.

Well-led

Requires improvement

Updated 22 November 2019

We rated it as Requires improvement because:

  • We found the service did not have systems or procedures in place to ensure policies were regularly reviewed or referenced the most up to date guidelines.

  • There was no audit of risk assessments and we did not find evidence that staff had clear oversight to the risk assessments or governance processes of the service.

However:

  • Staff we spoke with were very positive about the registered manager and their role within the service. Staff felt confident to raise any concerns and told us they were well supported.

  • The service had a vision in place for what it wanted to achieve. The registered manager told us the vision was to ‘focus on providing and improving a first-class family friendly service and to offer a warm and calm environment with safety being the priority’.

Checks on specific services

Diagnostic imaging

Requires improvement

Updated 22 November 2019

We rated this service as requires improvement because it did not have effective governance systems in place, to manage risks, to ensure policies were right for the service and pre-employment checks took place.