Precious Glimpse - Roundhay

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that women had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring women were at the centre of their care. We also looked for evidence that the registered manager instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we inspected but did not rate this key question. At this assessment the rating has changed to inadequate. We found new breaches of regulation 12 and continuing breaches of regulation 12. This meant the effectiveness of people’s care, treatment and support did not achieve good outcomes and was inconsistent.

We have not awarded this service a score for Effective.

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

The evidence showed significant shortfalls. The service did not make sure women’s care and treatment was effective because the registered manager did not check and discuss women's health, care, wellbeing and communication needs with them.

The registered manager did not assess women's needs prior to arrival at the service or prior to scans.

People contacted the service through a social media platform messenger service which directed them to a mobile telephone number, and then the registered manager called them back to make an appointment.

Women we spoke with who had recently used the service, all said they confirmed their date of birth at the point of booking. They completed their initials, signature and date on a waiver/consent form on arrival, prior to having a scan. However, the form did not include a robust individualised risk assessment or prompt women to disclose any specific health risk criteria, mobility issues, high BMI or communication needs.

We asked women what questions they were asked immediately prior to scanning. All confirmed they were not asked any questions about health history or any specific personal needs.

The registered manager explained they would respond to different individual needs on a case-by-case basis, although they acknowledged these were not identified at the time of booking. We requested but did not receive any pre-scan assessment documentation such as pre-scan check forms.

We asked the registered manager how they assessed people to ensure equipment was safe for them to use. They told us there had been no occasions when a person was inappropriate to scan. Although the scanning couch was unsuitable for people with a high BMI which exceeded the load limit of the equipment, the registered manager did not ask people to confirm their weight and there were no weigh scales or any other means to calculate BMI.

Women could ask for drinking water as needed or required, although there was no water dispenser for them to use. Bottled water we saw was stored inappropriately on the floor and on a shelf with potentially harmful cleaning products and associated equipment in the utility store room. This meant there was a risk of cross contamination.

The evidence showed significant shortfalls. The service did not always follow current evidence-based good practice and standards when delivering care. They did not always plan and deliver people’s care and treatment, in accordance with national best practice guidance.

All hard copies of policies we saw onsite were past the review date of 2022. The registered manager told us all current policies were held electronically and were not available to view at the location. Although requested, we did not receive any up-to-date policies for the service. This meant it was unclear how the provider was assured the registered manager always worked in accordance with current legislation and national best practice guidance.

The waiver/consent form stated scans were conducted in accordance with national guidance and recommendations. The registered manager told us the machine’s ultrasound frequency was set to be as low as reasonably achievable (ALARA), for length of scans and frequency of ultrasound sound waves. However, we did not see any policies or protocols on site for each type of scan offered and the associated ultrasound machine settings. The registered manager told us these protocols were held electronically and not available to view at the location. We requested but did not receive them after our assessment.

The registered manager could not demonstrate they knew about any relevant, current national guidance to underpin their practice.

The evidence showed some shortfalls. The service did not always work with NHS services when required to support women.

The service contacted the local NHS maternity services, such as the early pregnancy unit, with people’s consent, where there was an identified need. This was indicated on the waiver/consent form. However, some women did not disclose GP and maternity provider details on the forms, which meant there was a potential risk to their health and wellbeing, if they needed medical attention.

The registered manager kept a record of all onward referrals. However, we requested but did not receive the provider’s policy to deal with a concern when a baby’s heartbeat was not detected, or the provider’s policy for information sharing with a person’s GP and maternity care provider.

The evidence showed significant shortfalls. The service did not support people to manage their health and wellbeing. The service did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

The service had no health promotion information available on their social media page or at the service. They did not promote, mental health wellbeing, healthy eating, smoking cessation, infant feeding or safe sleeping awareness, for example.

We discussed this with the registered manager who told us the purpose of the service was ‘solely to check there was a baby in the right place, with a yolk sac, measure the fetus to estimate gestational age and confirm heartbeat’. This meant there were missed opportunities to support women and pregnant people to manage their health and wellbeing.

The evidence showed significant shortfalls. The service did not monitor women’s care and treatment to continuously improve it. The registered manager did not ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of women themselves.

The registered manager did not monitor the quality or effectiveness of care and treatment through audit and benchmarking to compare with other similar services. They confirmed there was no audit schedule and no policies or processes to monitor scan consistency and quality.

The registered manager told us about a recent incident where the result of a gender scan was incorrect. However, they had not sought any refresher training or peer review to address learning needs and reduce the risk of this happening again. They confirmed that when people were unhappy with scan quality, they were offered a free repeat scan or a refund.

The evidence showed significant shortfalls. The service did not tell women about their rights around consent or respect these when delivering care and treatment.

The registered manager did not support women and pregnant people to make informed decisions about their care and treatment. They were unclear how to support people experiencing mental ill health or those with mental capacity issues, to make decisions about their care.

We requested but did not receive the provider’s consent and mental capacity policy or any mental capacity training records. The registered manager could not demonstrate they understood how and when to assess whether a person had the capacity to make decisions about their care. This meant it was unclear how they ensured they always followed national guidance to gain people’s consent.

A short summary of the ultrasound scan procedure was included on the consent/waiver form, in accordance with online NHS guidance and it referred to ALARA guidance and recommendations for length of scans and frequency of ultrasound sound waves.

The waiver/consent form section ‘assumption of risks’ stated the woman ‘acknowledged inherent risk in any activity involving a fetus’ and that there were ‘potential risks in this type of activity’.

Health Protection Agency (HPA) current guidance states, although there is no clear evidence that souvenir baby scans are harmful to a fetus, women must decide for themselves if they wish to have a scan and balance the unknown risk. The consent process on the waiver/consent form took this guidance into account and referred to national institute for health and care excellence (NICE) and British medical ultrasound society (BMUS).

Women were asked to read this prior to providing initials, date and signature. However, women we spoke with who were recently scanned, told us the registered manager did not discuss any risks with them and they did not receive a copy of the waiver/consent form after signing it.

In addition, the waiver/consent form titled ‘Client information and waiver Precious Glimpse Ltd’ (the franchisor) was not localised to reflect that the agreement was between the person and Precious Glimpse Roundhay. It stated scans would be performed by Precious Glimpse Ltd and that the woman ‘voluntarily assumed all risk of harm or injury to them or their baby resulting from services provided by Precious Glimpse Ltd’.

The waiver/consent form also stated the service provided a chaperone if requested. However, as the registered manager was the sole employee, it was unclear how this could be achieved.

The registered manager told us they used women's familiy members or an online interpretation application to support women to give informed consent, where necessary, when English was not their first language.