Precious Glimpse - Roundhay

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

We looked for evidence that safety was a priority for everyone, and that the registered manager embedded a culture of openness and collaboration. We found new breaches of regulations 12 and 15 and continuing breaches of regulation 12. The service did not have systems for identifying and responding to women or their companions who suddenly became unwell. Women did not receive treatment and care to reduce the risk of avoidable harm, which included individualised risk assessments, and equipment safety checks prior to scanning. Women were not safe from neglect, abuse and discrimination. Women did not give fully informed consent prior to procedures.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. Women were not safe and 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 evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Although requested, we did not receive a current incident reporting and reviewing policy, which reflected the provider and national guidance. This meant the service could not demonstrate how it managed safety incidents, or that they managed safety incidents well.

The service did not provide a completed action plan or any examples of changes to address previous regulatory breaches, improvements to safety or quality and governance since our last inspection. The registered manager could not give examples of any quality improvements made as a result of feedback from women and their companions.

The registered manager told us they had not recorded any safety incidents or near misses and did not demonstrate a clear understanding of the duty of candour. Although requested, we did not receive the provider’s Duty of Candour policy.

The evidence showed significant shortfalls. The service did not work well with women and health system partners to establish and maintain safe systems of care. They did not manage or monitor women's safety. Records were not sufficiently comprehensive to make sure there was safe care.

Although requested, we did not receive the provider’s admission or exclusion policy with associated risk assessments for each woman attending the service. We identified this as a concern at our previous inspection and there were still no clear criteria for limitations in the service, which might preclude scanning. For example, persons under the age of 18, those with complex health needs and women with bariatric equipment needs.

Although requested, we did not receive the provider’s first aid policy outlining local arrangements in the event of a sudden illness or life-threatening situation. The registered manager told us they always carried their mobile telephone and would call an ambulance. However, there was no risk assessment for lone-working and management of such an emergency.

Women's records were a mixture of electronic and paper documents. We found records were not comprehensive, and the registered manager did not store them securely when unattended. For example, we saw waiver/consent forms and onward referral records kept in ring binders at reception. The computer used to upload and send images to the printer, located in reception was not password protected, which was a concern identified at our previous inspection.

The registered manager told us they referred women to the local NHS maternity service if they detected a non-viable pregnancy. However, although requested, we did not receive the provider’s policy or pathway for this process.

The evidence showed significant shortfalls. The service could not demonstrate the registered manager was trained appropriately. The service did not work well with women and healthcare partners to protect their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The registered manager did not concentrate on protecting women's rights to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Although requested, the service did not provide any safeguarding policies which reflected current national safeguarding guidance for adults and children, including where children were visitors.

The registered manager told us they completed safeguarding vulnerable adults level 2, safeguarding children level 3 and PREVENT (anti-racialisation) training online. Although requested, we did not receive any training records.

The registered manager did not demonstrate consideration of safeguarding concerns when booking women for scans. For example, there were no prompts on the waiver/consent form to document any possible safeguarding issues such as domestic abuse. The registered manager was unclear of their legal duties regarding disclosure of female genital mutilation (FGM) and did not know how to report it appropriately.

The registered manager told us they knew how to contact the local authority, although they had never had cause to do this. However, there was no system to record safeguarding referrals.

Posters which directed women to safeguarding help were displayed on the inside of the toilet door. There was no other material displayed in public areas, which meant people would not see it unless they used the toilet.

The registered manager confirmed they submitted a Disclosure and Barring Service (DBS) certificate to CQC in 2019 at registration. They told us they reapplied for a DBS certificate in March 2026. Although requested, we did not receive any updated DBS certification or application documents.

However, we saw a DBS certificate for the Precious Glimpse Roundhay service dated 2019, and associated photographic identification for another person, who was not the registered manager. The registered manager confirmed this person was not employed at the service and could not explain why these documents were on file.

The service was not registered to provide services to young people under the age of 18. The registered manager told us women confirmed their age verbally and recorded it on the waiver/consent forms. However, if on arrival a woman appeared to be under the age of 18, they were not scanned, unless they provided photographic identification.

The evidence showed significant shortfalls. The service did not work well with women to understand and manage risks. The registered manager did not provide care to meet women's needs, that was safe and supportive.

The registered manager did not complete documented risk assessments prior to scanning women. People recorded their date of birth and initialled a declaration on a waiver/consent form, that they were ‘in good health’ with ‘no new or ongoing health concerns or allergies’. However, there was no prompt or space on the form for them to disclose significant risks such as abdominal pain, any vaginal bleeding, multiple pregnancy, previous significant health history, or allergies. The registered manager did not ask women about their weight or body mass index (BMI), which might mean the scan couch was unsuitable for them.

The registered manager told us they discussed current maternity care at the time of booking. However, we did not see this information recorded on waiver/consent forms. Women we spoke with told us they were not asked about past medical history or discussed any associated risks. One person told the registered manager had not asked about previous health history, previous pregnancies or any problems during their current pregnancy. Another told us they thought the registered manager did not need to ask anything because they knew them from previous pregnancy scans and their information was on the computer.

The service provided complimentary promotional gift bags, which contained a brochure dated 2021 and oral vitamin D drops, which were past the manufacturer’s expiry date. We discussed with the registered manager that in providing vitamin D drops, they may be acting outside the scope of their registration. In addition, they did not ensure women and their babies were risk assessed prior to providing vitamin D drops. This meant there was a risk of potential ill effects, which are documented in current national guidance. This advises vitamin D supplements are only recommended for breast-fed infants, as formula feed is already fortified. The registered manager told us they would dispose of them.

The registered manager did not provide information so that people could access advocacy and available local services if required.

The waiver/consent form prompted people to provide GP contact, NHS hospital details and estimated due date, although this was not mandatory. People were not asked to disclose date of last and next NHS scan, and the registered manager told us they would not be concerned should women request repeat scans. There was no process in place for monitoring frequent attendees or risk reviews.

This meant there was a risk unborn babies may be exposed to very frequent ultrasound scans. Current national guidance including NHS, National Institute for Health and Care Excellence (NICE), British Medical Ultrasound Society (BMUS) and Royal College of Obstetricians and Gynaecologists (RCOG), does not recommend souvenir scans because risks to health of developing babies are currently unknown and research is ongoing. However, this information was noted on the waiver/consent forms.

The evidence showed significant shortfalls. The service did not detect and control potential risks in the care environment. The registered manager did not make sure the equipment, facilities and technology supported the delivery of safe care. Risks in the environment were not fully mitigated.

Access to the premises through the front door was unrestricted. We were concerned lone working risks and lack of a lone working policy, identified at our previous inspection, were still not sufficiently mitigated. We requested but did not receive the provider’s lone working policy.

We requested but did not receive the provider’s health and safety policy, which reflected local arrangements in line with national guidance. This meant the service could not demonstrate how they managed health and safety effectively.

The design, maintenance and use of facilities, premises and equipment did not keep people safe. For example, the fabric of the premises was poorly maintained. There was mould growth on the toilet window frames and areas of paint loss, bubbling paint and staining on the walls in the reception area and scan room, which could not be wiped clean. This posed a potential risk of harm to people with respiratory problems and allergies to mould spores.

The utility store room where items subject to Control of Substances Hazardous to Health (2002) (COSHH) regulations and associated cleaning equipment were kept, was accessible from reception and not locked when unattended. This meant harmful substances were potentially accessible to unauthorised persons, including children, when the registered manager was in the scan room.

We found dirty mops and rubbish stored on the floor immediately adjacent to bottled drinking water in the store room. There was a baby’s sip cup which contained orange liquid, stored on a shelf immediately next to hazardous cleaning products. In addition, we found multiple spray bottles of bleach stored at floor level and easily accessible to children, in the scan room.

At our previous inspection, we found the contents of the first aid box were past the manufacturer’s expiry dates and unfit for use. At this assessment, the contents had expired in 2025. This meant robust checking systems were still not in place to ensure equipment was always suitable for use when required.

Fire extinguishing appliances were all wall-mounted and serviced within the last 12 months. A poster in reception directed people to an assembly point on the street. There were fire exits to the front and rear of the premises. However, the rear door had a ‘no exit’ sign on it and multiple locks, which would hamper escape if there was a fire in the reception area, between the scan room and front door. Although requested, we did not receive the provider’s fire policy or current fire risk assessment to show how this risk was mitigated.

The service sticker on the scan machine indicated a service was due in December 2025 and the registered manager told us this was done in January 2026. Although requested we did not receive any documentation to show the machine was serviced, maintained and calibrated in accordance with the manufacturer’s instructions.

We requested but did not receive the provider’s standard operating procedure for daily safety checks, including calibration of the scanner and the registered manager was unable to provide any records of daily safety checks for associated scanning equipment.

However, portable electrical appliances we saw had been safety tested and labelled to show when the next test was due.

The main reception area was uncluttered, bright and comfortable with upholstered seating which could be wiped clean and vinyl flooring.

There was a display of baby-souvenir items for sale, such as soft toys, which could have a recorded fetal heartbeat inserted. These were all CE marked. CE marking is a certification mark that indicates conformity with health, safety, and environmental protection standards for products sold within the European Economic Area (EEA).

External signage was clear and there was free on-street car parking nearby. The service premises were on the ground floor. The main entrance was at street level with a ramp to the door.

Local authority removed domestic waste from the premises weekly.

The evidence showed significant shortfalls. The registered manager did not keep up to date with mandatory training and did not undertake any refresher competency training. They did not access effective support, supervision and development.

The registered manager was the sole employee at the service and there were no vacancies. We requested but did not receive the provider’s recruitment and induction policy, which reflected local arrangements for pre-employment checks, including requirements for DBS checks.

The registered manager explained the franchisor delivered initial scan competency training in 2019. However, they had not completed any subsequent refresher competency training.

The registered manager told us they accessed mandatory training in key skills online. Modules included, for example, health and safety, basic life support, first aid, information governance, fire, infection prevention and control and hand hygiene. However, although requested, we did not receive the provider’s mandatory training policy or any mandatory training records for the registered manager, althought they delivered the regulated activities.

The registered manager could not demonstrate that they completed training on recognising and responding to service users with, for example, mental health needs and learning disabilities.

They could not demonstrate they knew how to access appropriate national guidance. They could not explain how they used changes in national guidance, incidents, safeguarding and appraisal of personal development needs to identify gaps in their learning.

They did not access effective support, supervision and development and had not been in contact with the franchisor for over 4 years. This meant there were missed opportunities to share experience and learn from other staff within the franchise group.

The evidence showed significant shortfalls. The registered manager did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The service did not manage infection risks well. The registered manager did not use equipment and control measures to protect women, themselves, and others from infection. They did not keep equipment and the premises visibly clean.

We requested but did not receive the provider’s infection prevention and control (IPC), waste management and blood borne virus policies or supporting guidance. There were no processes to enable a safe response to IPC risks such as transmittable infections.

The scan room door and scan room environment were visibly dirty. The scanner and furnishings, including the scan couch, were dirty and presented a potential IPC risk.

The registered manager decanted ultrasound gel, which was past the manufacturer’s expiry date, into reusable bottles for use during scanning. Current British Medical Ultrasound Society (BMUS) national guidance strictly advises against decanting ultrasound gel from larger containers into smaller, reusable bottles to prevent infection transmission.

We saw a waste bin that had no liner but contained waste tissues and used paper couch roll.

There was no programme of IPC audits, no cleaning schedules and no cleaning records. This meant the service was unable to demonstrate that the environment and equipment, including the scanner transducer probe, was clean and fit for purpose before scanning women.

The registered manager told us they used the wash hand basin in the toilet to wash their hands and used alcohol hand gel prior to conducting scans. However, the hand gel we saw kept on the scan machine was out of date, had no lid on the container and the nozzle was clogged with dried gel.

We saw boxes of non-latex gloves available, but they were very dusty and the registered manager told us they used them rarely. We found unboxed, dusty face masks stored on top of the heating boiler.

There was no spill kit or formal process in place for managing spillage of body fluids at the service.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.