Himom 4D Baby Bonding Studio

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

At our last assessment we rated this key question good. At this assessment the rating was downgraded
and is now inadequate. This meant people may not be safe and were not protected from avoidable
harm.

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.

The service did not have a culture of safety based on openness. There was a lack of assurance
that concerns about safety would be listened to and investigated. Lessons were not learnt to
identify and embed good practice.
Staff were uncertain of incident reporting, what should be reported or any incidents that had
been reported. We were sent the incident reporting log, however there was no record of any
incidents documented on this despite the incident policy identifying that all incidents should
be reported in the incident log. The incident policy provided was dated 25 June 2022 to be
reviewed by 25 June 2023, but there was no evidence that a review had been undertaken.
We saw no information about potential clinical (or other) incidents which had been reported.
We asked the provider for examples when things had gone wrong around patient management
such as incorrect gender. They told us there had been no clinical incidents. However, on the day
of our assessment we found there were potential concerns around 3 patients who required
further medical review. A lack of recorded incidents meant there was an inability to review and
when appropriate learn from these incidents.
The operations manager told us they had received limited patient feedback. They said they had
recently started to ask patients to complete a feedback questionnaire whilst they were in the
service. Patient feedback on the day of our assessment was generally positive.

The service did not work well with people and health system partners to establish and maintain
safe systems of care.
Staff did not ensure there was continuity of care when people moved between different
services. The provider did not have appropriate processes in place to escalate unexpected or
significant findings identified during ultrasound scans, such as a possible concern. The service
referral policy incorrectly identified actions to be undertaken if any concerns were identified for
example referral to gynaecology services if under 20 weeks pregnant. Arrangements identified
within the policy may delay further patient review and timely actions to ensure patient safety.
Patients were given information about the findings of the scan to give and were told to give the
information to their GP or midwife. The service did not connect other health services to share
their findings

The service did not have effective systems in place to keep people safe from bullying,
harassment, abuse, discrimination, avoidable harm and neglect.
Staff had not received appropriate safeguarding adults and safeguarding children training. We
saw during the assessment that the operations manager had undertaken safeguarding adult
level 3 training. However, this training should have been updated in September 2025 and had
not been. The provider was also the clinician who performed scans had done safeguarding
adults level 2 training online the day before the assessment. The provider was unable to
demonstrate how they had assessed the competencies required to ensure that people had the
skills to protect people from neglect etc. For example, the intercollegiate document
recommends clinicians with face-to-face contact with people should have safeguarding adults
training to level 3. The intercollegiate document is a framework designed for all health and care
organisations to ensure staff are equipped to identify safeguarding issues and provide
personalised, culturally sensitive support.
The service also saw clients under 16 who were accompanied by an adult and women were
accompanied by their children which meant safeguarding children level 2 training should have
been undertaken. Following our assessment, we asked for evidence staff had undertaken the
required mandatory training which included safeguarding adults and children. No information
was provided. This meant we were not assured that staff would recognise abuse or take
appropriate actions to keep people safe.
Safeguarding policies were available for children and adults. However, both policies were out of
date and were due for review in June 2023. There was no evidence to demonstrate that the
review had been undertaken. The policies did not include all required detail for example all
types of abuse, levels of training required for staff or a correct contact number for the local
safeguarding teams for adults and children. This meant staff may not take appropriate or
timely action to recognise abuse keep people safe.
There was no evidence the service worked with other organisations such as the local
safeguarding team to discuss any concerns or make referrals. During the assessment the
operations manager was not aware of how to contact other organisations for advice such as the
local authority safeguarding team. No safeguarding referrals had been made.
There were no systems for women to speak alone and in private with staff should they wish to
highlight any concerns such as domestic violence or coercive behaviour.

The service did not work well with people to understand and manage risks. Staff did not
provide care to meet people’s needs that was safe and supportive.
The clinician did not confirm patients’ identification before the scan procedure as per guidance.
This was raised with the provider as a significant risk on the day of assessment and was
addressed. Not confirming patient identification could risk the wrong scan procedures being
carried out on the wrong patient or incorrect information being provided, for example a request
not to identify the gender.
During our assessment we saw patients scans which may need further medical review. We saw
whilst the sonography was kind and compassionate they did not correctly identify actions the
patient should undertake to seek further and timely medical review. This meant there may be a
delay in the patient timely care and treatment.

There was no effective system to ensure safety, upkeep, and repairs for buildings and
equipment. The service did not always detect and control potential risks in the care
environment or ensure facilities supported the delivery of safe care.
We found a lack of health and safety, fire checks and procedures in place, which may put
people at risk of harm. The fire alarm service was overdue, this had been due in May 2023. The
emergency lighting maintenance checks should also have been reviewed in May 2023, but there
was no record of this having taken place. We did not see regular staff fire drills undertaken and
no evidence of regular arrangements. During our assessment we noted that a fire alarm was
recorded as being checked the day before our assessment.
Cleaning chemicals which included substances hazardous to health (COSHH) were being stored
in an unlocked cupboard in the kitchen. The kitchen door was open and accessible to patients
and those who accompanied patients including children. This meant people were at risk of
serious harm to poisoning or chemical burns.
Managers said the responsibility for arrangements for service contracts for the premises were
the landlord’s responsibility. However, they failed to recognise their legal responsibilities under
the Health and Social Care Act to ensure the facilities, premises and equipment were
appropriately maintained.
There was appropriate servicing, maintenance and checks of the scan machine.

The service did not make sure staff were suitably qualified, skilled or experienced staff. They did
not always make sure staff received effective support, supervision and development that met
people’s individual needs.
The service did not have safe recruitment practices. We reviewed the pre-employment checks
of 5 current and past staff members through the available files on site. We found 3 staff files
included a Disclosure and Barring Service (DBS) check from another health provider but
included no further information such as a risk assessment detailing whether this was sufficient.
DBS is a UK service to help employers make safer staff recruitment decisions by checking a
person's criminal record.
There were no employment references for any of the 5 staff members we reviewed. There was
no evidence the staff members’ right to work in the United Kingdom (UK) had been checked for
any of the staff we reviewed.
There were no staff files with employment checks available for 2 of the current staff members
who were observed to be working on the day of our onsite assessment. During our assessment
we also found that all staff files were not complete and did not have all required information.
The lack of employment checks required by the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 put patients at risk of avoidable harm from unsuitable people
being employed.
Staff members did not have the required skills or competence to carry out their roles which put
patients at risk of avoidable harm from poor or unsuitable practice. During the assessment the
provider failed to demonstrate appropriate knowledge of updates in pregnancy scanning,
including adherence to best practice guidelines such as ensuring the number of ultrasound
scans was kept to a minimum and contact with early pregnancy units. There was no evidence of
any independent or peer review of scans and scanning procedures by the provider.
There was no record of staff mandatory training completion provided to us despite requesting
it during and immediately after our onsite assessment on the 18 October 2025.
Further information sent by the provider a month following our assessment did include recent
mandatory training, however this was not for all staff and did not include all required
mandatory training such as infection prevention and control and safeguarding training. This
meant we were unable to assess whether staff were appropriately trained, skilled or competent to carry out their roles.

The service did not assess or manage the risk of infection.
We found poor infection control practices which were not in line with the Health and Social
Care Act 2008: Code of Practice on the prevention and control of infections which may put
people at risk of harm. We saw the clinician/ sonographer did not wash their hands between
patients. We raised this as a concern during the assessment to ensure required hand washing
was undertaken. However, there was no handwashing sink in scan room. Handwashing sinks
did not have suitable taps which met the infection control requirements. The operations
manager at the location said no infection control audits were regularly undertaken.
There was a weekly cleaning checklist which was a tick list however the checklist was not fully
completed and therefore we were not assured cleaning had been completed. Tasks in the
cleaning checklist included polishing, cleaning toilets and kitchen surfaces. It also identified
“hoovering and mopping may also be required”. The cleaning policy identified management
would sign off the cleaning checklist weekly, but we did not see evidence this had been
undertaken. The operations manager said audits of cleanliness were not undertaken.
Chairs within the clinic were fabric covered and were not easily cleanable. There were carpets in
the waiting room and scan room which appeared shabby and marked. No records were
available to identify when they were last cleaned.

The service did not use medicines and this key question was not reviewed.