Himom 4D Baby Bonding Studio

On this page

• 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

At our last assessment we rated this key question requires improvement. At this assessment the rating
has been downgraded to inadequate This meant there were widespread and significant shortfalls in
service leadership. Leaders and the culture they created did not assure the delivery of high-quality
care.

We have not awarded this service a score for Well-led.

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

The evidence showed significant shortfalls. The service did not have a shared vision, strategy
and culture based on transparency, equity, equality and human rights, diversity and inclusion,
and engagement. They did not understand the challenges and the needs of people.
We found there was a lack of vision and direction for the service and a general failure to update
on current required practice and guidelines.

The service did not have leaders who had the skills or knowledge to lead effectively.
We found several examples that the provider and managers did not have the knowledge and
skills to provide a safe and effective service which met the requirements of the Health and
Social Care Act 2008 (Regulated Activities) Regulations. The service was in breach of the
regulations for safe care and treatment, good governance and employing fit and proper staff
There was both ongoing non-compliance with the Health and Social Care Act 2008 (Regulated
Activities) regulations and from previous inspection in addition to breaches of regulations
identified within this report. We also found:
The provider was not registered with the Care Quality Commission (CQC) to deliver a service to
people younger than 18. No notifications had been submitted to CQC to request a change to the
service user bands to enable CQC to assess if the service was suitable to be provided to under
18-year-olds.
The performance rating of the service was not displayed within the service which is required
under Regulation 20a of the Health and Social Care Act. In addition, we highlighted before our
assessment the provider was also not displaying their performance ratings on their website.
During our assessment this had been amended but only identified the overall performance
rating and not all key question ratings.
Leaders were uncertain who held legal responsibility for the service. When asked managers
provided different names, this meant there was a poor knowledge of legal accountability to
ensure the service was appropriately and safely managed within legal requirements.
Leaders were visible in the service and approachable for patients and staff. The provider who
was the clinician/ sonographer was always onsite when the clinic was open with patients
booked for scans. The operations manager and booking manager were both usually onsite or available by telephone.

There were insufficient arrangements to support people to speak up and enable their voices heard.
There was no independent system or person staff could speak to if they had any concerns. The
operations manager told us staff could come to her but in a very small organisation staff may
not feel comfortable to do so. Freedom to Speak Up (FTSU) encourages a positive culture where
people feel they can speak up, their voices heard, and their concerns acted upon. Whilst the
requirement is for NHS organisations its important similar systems are available to support
people in all health and social care services to raise concerns in a safe and appropriate way.
Information was available to staff working within the service which identified ‘that if at any
point you're unhappy about anything, please voice to your line manager or directly to your
operating manager as we are a team and we can only know how to help or explain a situation
and / or change a situation we are aware of your views and feelings.’
Patients were asked to provide feedback although limited feedback had been received

The evidence showed significant shortfalls. The service did not value diversity in their
workforce. They did not work towards an inclusive and fair culture by improving equality and

The service had minimal evidence to provide assurance that workforce equality diversity and
inclusion were met. The operations manager provided all the policies and procedures, but no
Equality and Diversity policy was made available to us. The premises were not suitable for
people with mobility difficulties as entry was via several external steps.
Staff were employed on zero-hour contracts and only booked on shifts they were able to work.
There was no evidence available of reasonable adaptations for staff.
There was no equality monitoring of staff within the service and so they were unable to show
staff makeup represented of the patient group

The service did not have clear responsibilities, roles, systems of accountability and good
governance. They did not act on the best information about risk, performance and outcomes,
or share this securely with others when appropriate.
There were no structured governance arrangements to review the performance of the service
There was no system to review policies and procedures and ensure best practice was identified
and shared with staff. There were no audits of the service, including risks, complaints. patient
records and infection control. There was no monitoring staff received required mandatory
training or recruitment and selection met the requirements of the regulations.
There were no formal minuted governance meetings to review the performance of the service.
The operations manager told us managers used a WhatsApp group to communicate about the
service but there were no records available to corroborate this.
There was poor oversight of risk which included no or lack of incident reporting and ineffective
systems to mitigate against risk. There was no risk register and no system to provide assurance
that the service provided was safe and met patients’ needs. The lack of effective incident
reporting meant there was no system to learn from incidents and complaints and make
improvement when required.
There were no plans in place to ensure compliance with the Health and Social Care Act 2008
(Regulated Activities) regulations, and ongoing the breach of regulation 17 good governance
had not been actioned from our previous assessment.
There were no clinical audits and therefore no assurance safety needs of the patients were met.
There were appropriate systems in place to securely store patients electronic information
including patients scans with back up arrangements in place .

The service did not understand their duty to collaborate and work in partnership, to ensure the
service worked seamlessly for people. They did not effectively share information or collaborate
for improvement.
The provider told us they only provided ‘souvenir’ scans and did not provide a diagnostics
service; this was identified both on their website and on patient information provided.
However, their web site did identify they provided “assurance” and ‘presentation’ (position of
the baby towards the end of pregnancy) which exceeds a ‘souvenir’ scan.
The service did not have clear referral pathways. The provider had not developed established
relationships with partners in care to ensure that they worked with other stakeholders to keep
people safe.
There were no effective arrangements for partnerships with safeguarding teams to ensure
access to timely and appropriate advice and actions

The service did not focus on continuous learning, innovation and improvement both across the
organisation and local system. The lack of incident reporting meant there was an inability to
review and when appropriate learn from incidents.
The service had not sought advice to develop [practice for example in infection control and
safeguarding. There were no plans in place to ensure compliance with the regulations and
develop and improve the service. There was continued non compliance with the regulations.
They did not encourage creative ways of delivering equality of experience, outcome and quality
of life for people. They did not actively contribute to safe, effective practice and research.