Meet Your Miracle- Coventry

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

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this assessment, the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of the legal regulations relating to safe care and treatment, infection prevention and control, risk management, safe environment and staffing.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety. Risks to people were not used to learn and improve. For example, incidents within the clinics were not always recorded. Therefore, the service could not effectively monitor for themes and trends. The provider did not consider any level of harm to patients should there be an incident. All staff we spoke with were not clear on what an incident was and had not reported an incident. There was no incident management policy which meant there was no clear guidance for staff on how to report an incident, what an incident was and a clear process to follow. No incidents had been recorded at either Chesterfield or Coventry clinics within the last 12 months. A brief incident management policy was written following the assessment. However, we saw there was some learning from incidents at other satellite clinics. We reviewed team meeting minutes for Coventry clinic for January 2025 and saw a data protection breach from another clinic was discussed and staff were reminded of the correct procedures.

The service mostly worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Patients were referred to NHS providers where an anomaly was found. Policies were in place for this.

The service did not work well with people to understand what being safe meant to them and how to achieve that. There were limited effective safeguarding systems, processes and practices in place to make sure people were protected from abuse. We found staff had not all received the appropriate level of safeguarding training required for their job role. We were told all clinical staff were trained to level 3 safeguarding adults and children. The safeguarding lead was trained to level 4, whereas all non-clinical staff were trained to level 1 safeguarding adults and children. This was not in line with national guidance. Following the assessment, the service arranged training for all non-clinical staff in level 2 safeguarding. We saw 2 safeguarding referrals had been appropriately made between January 2024 and February 2025.

All staff knew who the safeguarding lead for the company was, but not all staff knew how to make a safeguarding referral. The policy was brief and did not contain the details of the safeguarding lead, how to make a referral, local authority details, definitions of abuse and how to act if abuse was seen. Following the assessment, this was updated to include details of the safeguarding lead but still was brief and did not contain detail about abuse, how to make a referral and what to do in the event of finding a safeguarding concern. On assessment, there were no policies within the policy booklet relating to children's safeguarding, child sexual exploitation and scanning young people. We were told anyone under the age of 18 had to arrive with an adult; there was no policy to confirm this and no checks to ensure whether the adult was an appropriate adult. Following the assessment, the service wrote an "Ultrasound Policy - Under 18's". The policy was brief. It did not state that a patient under the age of 18 had to attend with an adult and did not refer to any specific safeguarding to look out for when scanning patients under the age of 18. The policy stated that they did not see anyone under the age of 16. At Chesterfield, we were told they had scanned patients as young as 14. However, we did not see evidence of this. Following the assessment, we found the service was not registered to see anyone under the age of 18. We raised this with them, and they immediately stopped seeing anyone under the age of 18 for pregnancy scans.

The service did not always work well with people to understand and manage risks. There were a lack of policies and training in place to support patients who became unwell or where risks were identified. Staff did not have first aid or basic life support training. This meant if a patient became unwell on the clinic premises, the staff were not trained to administer basic life support or first aid treatment. Staff also gave us differing responses on how they would deal with a patient who became unwell. A member of staff told us they would call NHS 111 and others told us they would call 999. We were sent a medical emergency policy which contained basic advice about what to do if a patient became unwell. It also stated all employees must attend a basic first aid and emergency CPR training course in their first 6 months of employment; no employees had attended this course. Following the assessment, we were told all staff were 100% compliant with basic first aid and CPR training.

Staff were doing scans which were not souvenir scanning and were diagnostic. This was not in line with their `provision of non-diagnostic scans' policy. A sonographer told us they identified an ectopic pregnancy which involved scanning the fallopian tubes. The client referral policy also stated an example of a referral to the NHS would be ectopic pregnancy or fluid level above or below expected level at gestation; these would be identified by diagnostic screening tests rather than souvenir scanning only. We observed a sonographer completed a `crown, rump, length' measurement and gave the patient an estimated due date. We observed another scan where the sonographer measured the femur length and commented that it was a couple of days different to the estimated gestation. We were not assured that sonographers were practising in line with their training and not performing diagnostic scanning in line with their service policies.

There was a client referral policy in place which detailed what to do if an abnormality was found within the scan. Staff told us patients were referred to their local early pregnancy assessment unit (EPAU) following identification of an anomaly or concern. We were also told that women presented with symptoms such as bleeding as they could not get appointments within the NHS. Staff told us they could only tell the patients if there was a heartbeat or not and refer them to EPAU. Where abnormalities were found, the sonographer completed a report where they shared information noted during scanning leading to the referral for the woman to take to their local EPAU. The service had referred 77 patients into EPAU in 2024 between Coventry and Chesterfield. These were not logged as incidents within the clinics.

The sonographers completed femur and head circumference measurements. Where these measurements were not in line with the fetal gestation, the sonographer informed the patient if they were more than 3 weeks out of gestational expected age and told them to speak to their midwife. There was no policy which stated what to do if these measurements were out of range.

Staff were completing ultrasound scans for patients and ensured these were done in line with recommended exposure time for obstetric scanning. They had an ultrasound safety procedure and all staff had an observational assessment quarterly to ensure they were scanning in line with these guidelines. All patients were given terms of agreement which outlined that the British Medical Ultrasound Society (BMUS) did not recommend ultrasound for non-medical purposes and this was the patients choice. The terms of agreement included key information to keep women safe. All patients had to sign this at booking and on the day of the scan; it was held within their record. Consent documentation emphasised the fact that pregnancy scans were elective and non-diagnostic. Documentation clearly stated that measurements taken during scanning did not replace those made at NHS appointments.The service followed ALARA (As Low As Reasonably Possible) principle, which meant that equipment was set to the lowest possible settings, and a maximum amount of time set for exposure to ultrasound of 10 minutes. They had an Ultrasound Safety Procedures policy which detailed the recommended exposure times in line with national guidance. Re-scanning rates were monitored by the service.

The service completed non-invasive prenatal testing (NIPT) blood tests and early gender blood tests. They had a service level agreement with a laboratory who tested the NIPT blood sample once received in the post and followed up on the patient results. The service did not receive the results; these were sent directly to the patients. Results from gender testing were provided directly to the patient via an application.

All staff for Chesterfield and Coventry had completed their mandatory training in September 2024.

The service did not always detect and control potential risks in the care environment. Where there were risks in the environment, such as, carpets within the treatment rooms, appropriate risk assessments were not completed. We found several risks with the environment which were resolved following the assessment.

Staff did not make sure that equipment, facilities and technology supported the delivery of safe care. For example, we found flammable items which were not stored in a metal flammable cabinet as per Control of Substances Hazardous to Health (COSHH) regulations 2002. We also found many consumable items which were out-of-date since 2022. The provider took prompt action to resolve these safety issues.

The operations manager completed a quarterly visit to each site and looked at some aspects of health and safety. However, we saw several health and safety issues (at Coventry site) which had not been picked up by the audit when completed. For example, the fire extinguisher was out of date since 2022. There were also no risk assessments for staff, such as display screen equipment (DSE) assessments for staff who used the computers. This was not in line with national legislation. Staff also completed a monthly visual check of the equipment and building. There were no actions taken or any risks found within these audits despite the assessment team finding several. We were not assured that risks were detected and controlled within the clinics.

Staff at Coventry site did not follow the BMUS recommendation for quality assurance of ultrasound scanning machines. The BMUS recommend daily, weekly and monthly quality assurance. We saw cleaning of the machine, screen, ventilation and data deletion took place every 4 weeks at Chesterfield and Coventry in 2024. We saw evidence that the ultrasound scanning machine had an annual service, but we did not see evidence of quality assurance checks.

The facilities at Coventry did not meet the needs of the patients and their families. There were no bathroom for the patients. If they needed the toilet, they had to leave the premises and go in the supermarket next door. At Chesterfield, they had a toilet on site for women and their families to use.

The service took blood samples when required. These were taken within the scanning room. Sharps were disposed of correctly, but the bins were not labelled, and they were not stored safely. They were stored on a high up shelf, and you had to tilt the sharps bin towards you to remove it; this meant the contaminated sharps could fall out of the sharps bin. The provider took action following the assessment to resolve this.

The service had a fire risk assessment which was completed in January 2025 for both Chesterfield and Coventry clinics. Chesterfield fire risk assessment was complete with no actions. The fire risk assessment for Coventry was incomplete and did not detail the risks found within the clinic such as the out-of-date fire extinguishers. Following the assessment, a fire risk assessment was completed on the 30 January 2025, a push door release was added to the fire door and new fire extinguishers were purchased.

The service had enough staff. However, the provider did not ensure staff received sufficient training for their roles. The sonographers were not all suitably qualified to undertake diagnostic ultrasound scans. There were several staff who told us they had a sonography qualification but we saw 5 out of 14 staff who carried out scans did not. They were trained on site by the sonographers who had completed sonography training using a competency framework including observational signing off. They were signed off as competent to carry out scans by qualified sonographers. The "competencies for ultrasound practice in private baby scan clinics" (2022) Society of Radiographers (SoR) states "To ensure a safe, high-quality equivalent service provision in private clinics, the SoR recommends that ultrasound practitioners have a Consortium for the Accreditation of Sonographic Education (CASE)-accredited qualification or equivalent". We saw 9 out of 14 sonographers had CASE accredited qualification or equivalent. Further evidence of qualifications and appropriate competencies were requested but these were not sent for all sonographers.

We were told the service offered souvenir scans only and did not offer diagnostic scanning. However, we saw they also completed measurements including femur, head circumference and crown rump length which allowed them to establish an accurate gestational age. The guidance (SoR, 2022) showed that these would be competencies for sonographers who completed diagnostic scans rather than souvenir scanning. We looked at the competencies for 2 staff which were sent through by the service; these were incomplete and it was not clear if they had completed a final sign off. We raised this with the service, and they sent us final sign off sheets. However, we were not assured the training was in depth and in line with the guideline competencies from the SoR (2022). Following the assessment, the service sent an updated competency booklet which contained more competencies and additional sign off requirements.

The SoR had guidance called `Recommendations for education and training of specialist paediatric sonographers' (2023) which referred to specific training requirements for paediatric scanning. This was not referenced in the ultrasound policy — under 18s and there was no mention of any further training required to scan patients under the age of 18.

The service had low vacancy, turnover, and sickness rates and managers described the team as stable. They did not use any bank staff.

We were not assured that all staff had an up-to-date annual appraisal. We asked for the appraisal completion rate, and this was not provided. We were told the staff had an annual appraisal completed by their clinic manager. Sonographers had supervision every 6 months where the operations manager observed scans and made suggestions where required.

We reviewed a selection of staff files. We asked for 4 staff references to be sent for specific staff and the managers only provided 1 reference for 2 of the staff requested. The recruitment policy stated that staff would be offered the position providing satisfactory references and pre-employment checks had been received. We also saw a letter to a sonographer detailing how they had passed their probation and asking for them to provide 2 work references at their earliest convenience. We were not assured that references were taken for all employees ahead of them starting at the service; this was against their policy.

The service did not always assess or manage the risk of infection. For example, there were carpets and soft furnishings throughout the Coventry clinic. Cleaning schedules showed carpets were hoovered every other day, but staff did not know how the carpets or soft furnishings would be cleaned appropriately if there were spillages. The soft furnishings in the waiting room were not cleaned as part of the cleaning schedule. There was no infection prevention and control policy to inform staff of the correct procedure. Following the assessment, the provider took prompt action to improve infection, prevention and control (IPC) compliance. The service had created an infection prevention and control policy; however it was very brief and lacked important information. For example, it refers to `National Institute for Health and Care Excellence (NICE) guidelines' but does not reference the guidelines used. The service had also created a sharps bin policy and spillage policy.

The operations manager completed a quarterly walkaround of each clinic and cleanliness was looked at. However, this was not the focus of the audit and did not look at, for example, waste management, storage of sharps and cleanliness of carpets. This meant the service was not completing regular checks of the cleanliness and environment to ensure high standards for the patients. The National Patient Safety Agency recommends that refillable ultrasound gel bottles were not used. Following the assessment, the service changed all ultrasound gel to single use containers that were pre-filled. We observed staff completing scanning and they did not use hand gel between seeing patients; this was not in line with their IPC policy. Staff were 100% complaint with IPC training.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.