Meet Your Miracle- Coventry

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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

Well-led - this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care. We checked that leaders proactively supported staff.

At our last inspection we rated this key question good. This key question has been rated requires improvement. This meant there were shortfalls in service governance. Leaders did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance of the service and fit and proper persons checks.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Not all leaders understood the context in which the service delivered the treatment and support. The leaders did not always have the skills, knowledge, experience and to lead effectively. Managers did not have the appropriate knowledge to manage the service effectively. They lacked the knowledge around policies and procedures, health and safety requirements, training requirements, and governance to ensure the clinics were safe and well-led for the patients. However, staff felt the service was consistently well-led and the managers were very supportive. They told us the managers were friendly and approachable. Staff felt confident to discuss any concerns they had with them should the need arise.

The registered manager had failed to ensure the clinics were appropriately registered as locations to carry out regulated activities and to scan children. This meant they had scanned 13 16- and 17-year-olds without the registration to do so within the 6 months prior to this assessment. The clinics were also carrying out regulated activities from unregistered locations. The registered manager applied to register all 5 locations following the assessment and told us they would stop seeing under 18’s until they were registered to do so.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not have clear responsibilities, roles, systems of accountability and good governance. Staff did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The governance system in place had failed to ensure a consistently good service was delivered and had not identified the widespread shortfalls identified at this assessment. From the governance records we viewed, we saw that quality monitoring audits were not robust nor used meaningfully and whilst the provider had systems in place to oversee the service, these too had failed in identifying concerns.

There was no process to version control policies or procedures. We reviewed policies on site and found they did not contain a date or version number. The polices lacked detail and clarity and the service did not always follow its own policies. For example, the health and safety policy stated a fire drill should be completed every 12 months and staff told us this did not happen. We found policies which referred to legislation which had inaccurate dates. For example, the Data protection policy referred to the Data Protection Act 2008. This was updated following the assessment to 2023. However, the Data Protection Act legislation is from 2018. The infection control policy also refers to ‘NICE guidelines’ but does not reference the guidelines used. The other policies were updated following the assessment to include a version and date but still were brief and lacked important detail. The audits completed were minimal and did not cover all aspects needed to ensure the service was safe for patients. There was a lack of oversight of issues surrounding risk, health and safety, and infection control which were not picked up through regular audit.

There was a managers meeting every 3 months and managers then met with their teams to feedback information. Learning from complaints, audits results, risks and patient feedback were not discussed; they were very sales focussed. We were not assured that lessons were learned and actions were taken to improve compliance through the governance process.

There were 9 out of 14 members, including sonographers and administrators and managers who worked at Coventry and Chesterfield sites, who did not have Disclosure and Barring Services (DBS) checks completed. All sonographers had a completed DBS certificate, but 2 were not completed by the service. We did not see any DBS checks for administrative staff. Their policy stated only sonographers needed a DBS check and that all DBS checks were applied for by the provider on behalf of the employee before employment begins. DBS (2024) guidance states any role that is involved in providing health or care services and also has contact with patients advises at least a standard DBS check. The service told us they did not feel the admin team needed a DBS due to not working directly with children (without an adult present) or vulnerable adults. We did not see a risk assessment detailing this reason for not undertaking a DBS for admin staff. The service was not complying with their own policy or national guidance to keep their patients safe.

The service stored patient records for 28 days. The service had a policy which stated they followed the information commissioner’s office in relation to keeping of records. The policy stated as the scans were not for medical purposes and were not part of the NHS care pathway, they did not believe these records need to be retained longer than 28 days. They were unable to justify keeping scan images when they believed they were not a record of health, and the patients had been provided with a copy.

There was a risk register for Coventry and Chesterfield which was the same. It did not contain all the risks for Coventry clinic on it. For example, there was no risk assessment for carpets, needlestick injuries or blood spillages. The risks documented were brief, did not have review dates and did not contain all mitigations needed to reduce the risks. We saw this was not discussed at any meetings held within the clinics or between the managers. We asked the registered manager what the main risk in the clinic was and they told us it was sonographers offering medical advice; this was not on the risk register. We were not assured that managers were fully aware of the risks within the clinics and ensuring there were mitigations in place reduce potential harm to patients and staff.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.