Precious Glimpse - Roundhay

Precious Glimpse Roundhay (1-7064428704) has been operational since July 2019 and is a franchise of Precious Glimpse Limited (Ltd). The service provides non-diagnostic transabdominal ultrasound scans, to self-paying members of the public, that are over the age of 18 years. Their scanning service includes early scans from seven weeks gestation onwards, 2D, 3D,4D baby keepsake scans and gender scans.

The service is based in Leeds, close to public transport and nearby parking. The registered manager is the individual provider and currently the only member of employed staff.

We inspected this service using our comprehensive inspection methodology and carried out an unannounced inspection on 18 November 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.

The main service provided by Precious Glimpse - Roundhay was baby keepsake scanning.

Services we rate

We rated this service as Requires improvement overall because:

• Whilst staff had completed mandatory training in most core subjects, these did not include information governance or health and safety at work.

• The service did not always use control measures well, to protect service users themselves and others from infection.

• The design, maintenance and use of facilities, premises and equipment did not always keep people safe.

• The service did not have robust systems in place to manage all risks to women and their babies.

• Current risks concerning lone working were not sufficiently mitigated.

• There was limited assurance the service always provided care and treatment based on national guidance and evidence-based practice.

• The consent policy was not detailed and did not reference the Mental Capacity Act (2005).

• The service had a limited complaints policy and it was not always easy for people to give feedback and raise concerns about care received.

• Leaders did not always ensure that policies and documentation reflected best practice guidance and mirrored practice at the service.

• The service had limited systems and plans to identify risks and eliminate or reduce them.

• The exclusion policy in place did not include a robust risk assessment requirement for each woman attending the service.

• Digital information systems were not always secure.

• The service had a vision for what it wanted to achieve but required a long-term strategy with targets.

• Information about costs of services was unclear.

However, we also found that:

• Staff understood how to protect service users from abuse and knew how to contact other agencies to share concerns.

• The service had enough competent staff, and systems in place to assess and manage risks to women and their babies.

• The service had procedures in place to manage service user safety incidents.

• Staff monitored feedback from service users.

• Staff responsible for delivering care worked with other services to support users.

• Staff treated service users with compassion and kindness, respected their privacy and dignity, provided emotional support and took account of their individual needs.

• Staff supported and involved service users and those close to them to understand their condition and make decisions about their care.

• The service planned and provided care in a way that met the needs and preferences of local and individual people. Women could access the service when they needed it and received care promptly.

• Leaders were approachable in the service for service users and those close to them.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices with actions they must complete, that affected Precious Glimpse Roundhay. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North)