Archived: Tyneside Pregnancy Advice Centre

Updated 31 July 2019

Tyneside Pregnancy Advice Centre is operated by Foundation For Life. The service provides an opportunity to have a free ultrasound scan (use of sound waves to get pictures of the inside of a body) to adolescents and women who think they may be pregnant: specifically, the scan is limited to confirming the presence of a heartbeat in the womb. If it is not possible to identify a heartbeat in the womb the service user is referred to a local EPAU to exclude other possible diagnoses, such as, an ectopic pregnancy or miscarriage. The service sees adolescents and women who self-refer or who have been referred by their GP (or other healthcare professional). The service primarily served the communities of Newcastle Upon Tyne.

The service has had a registered manager in post since 2013. The service is registered for the following regulated activities:

• Diagnostic and screening procedures

We conducted a short-announced inspection of the ultrasound scan part of the service on 14 May 2019.

The service also offered: a pregnancy advice service and scanned volunteer adolescents and women, not as any part of their care or treatment, but for training purposes. We did not inspect these services.

Updated 31 July 2019

Tyneside Pregnancy Advice Centre is operated by Foundation For Life. The service provides an opportunity to have a free ultrasound scan (use of sound waves to get pictures of the inside of a body) to adolescents and women who think they may be pregnant: specifically, the scan is limited to confirming the presence of a heartbeat in the womb. If it is not possible to identify a heartbeat in the womb the service user is referred to a local early pregnancy assessment unit (EPAU) at the local NHS trust to exclude other possible diagnoses, such as, an ectopic pregnancy or miscarriage. It sees adolescents and women who self-refer or who have been referred by their GP (or other healthcare provider). 

The service is situated on the ground floor of a terraced house and is located a short walk from local public transport networks. The house is owned by a third party and is occupied by other businesses. Service users arriving were met by staff and directed to a reception room and waiting area. Adjacent to this (and moving down towards the back of the premises) was an advising room, a multi-sex toilet, the ultrasound scanning room, a store room, kitchen and staff toilet, ending with the fire exit. On the first floor were staff offices to which service users and the public did not have access.

The service provided an ultrasound scan to service users aged below 16 to 65 in relation to pregnancy (from the earliest stages of pregnancy at six weeks). Although not the primary purpose of an ultrasound scan, service users could take home with them a two dimensional non-colour picture of their ultrasound scan where appropriate.

We inspected this service using our comprehensive inspection methodology. We carried out the short-announced part of the inspection on 14 May 2019. We had to conduct a short-announced inspection because the service was only open at limited times during the week.

To get to the heart of experiences of care and treatment for service users, 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.

Services we rate

We had not previously rated this service which was registered on 1 October 2013.

At this inspection we rated it as Requires improvement overall.

We found the following issues, that the service provider needs to improve:

• Governance: the service had gaps in its clinical governance process that was in place to maintain quality and put safety of users of the service first. For instance, the service regarded the guidance for staff on discrete risks, such as premises and equipment, fire safety, aggression, and infection control, as its risk policy. However, this did not set out details of the tools and processes staff should use to assess risks, such as a risk management framework, or how staff measured performance on managing risks, plus there was no risk register. Further, lack of a quality assurance system around safeguarding referrals for adolescents engaged in sexual activity under the age of 16 but older than 13 (‘under age adolescents’); or no policy for the deteriorating service user.
• Children safeguarding: we found issues with: the policy for referring under age adolescents to safeguarding authorities; benchmarking with published national guidance of in-house training for staff about children safeguarding; having regard to such national guidance, the levels to which staff were trained in children safeguarding; staff undertaking ultrasound scans not being trained in spotting physical signs of female genital mutilation (FGM).
• Complaints: the location did not display any information to inform service users about their right to and how to complain about the service. Further, there was no independent body a service user could progress their complaint with after a final decision under the service’s complaints system had been made.
• Infection control: clinical waste was not disposed of in accordance with guidance set out in Health Technical Memorandum 07-01: Safe management of healthcare waste.
• Equipment: items of portable electrical equipment in use, such as electrical heaters or light stands, had not been safety electrical checked.

But we found the following areas of good practice:

• Staff training in mandatory training was up to date.
• The service was visibly clean and mostly un-cluttered and all ultrasound equipment seen had been maintained.
• The service used competent staff to do the scanning who had been appraised.
• If needed service users could be referred to the NHS and staff had a process to follow.
• The service ran to time, with no cancellations.
• The feedback forms we saw were positive about service user experience at the service.
• Staff we spoke with and minutes of meetings we reviewed showed an open culture where the leadership team were accessible and approachable.

Following this inspection, we asked the provider to provide us with an action plan to address our concerns above about children safeguarding. The provider supplied an action plan to address our concerns. This will be monitored by way of continuing engagement.

We also issued the provider with one requirement notice that affected the service. Details are at the end of the report.

Also, below we have suggested other improvements, even though a regulation had not been breached, to help the service improve.

Ann Ford

Deputy Chief Inspector of Hospitals (North)

Updated 31 July 2019

At this inspection we rated the service as Requires improvement overall.

We found the following issues, that the service provider needs to improve:

• Governance: the service had gaps in its clinical governance process that was in place to maintain quality and put safety of users of the service first. For instance, the service regarded the guidance for staff on discrete risks, such as premises and equipment, fire safety, aggression, and infection control, as its risk policy. However, this did not set out details of the tools and processes staff should use to assess risks, such as a risk management framework, or how staff measured performance on managing risks, plus there was no risk register; further, lack of a quality assurance system around safeguarding referrals for under age adolescents; or no policy for the deteriorating service user.
• Children safeguarding: we found issues with: the policy for referring under age adolescents to safeguarding authorities; benchmarking with published national guidance of in-house training for staff about children safeguarding; having regard to such national guidance, the levels to which staff were trained in children safeguarding; staff undertaking ultrasound scans not being trained in spotting physical signs of female genital mutilation (FGM).
• Complaints: the location did not display any information to inform service users about their right to and how to complain about the service. Further, there was no independent body a service user could progress their complaint with after a final decision under the service’s complaints system had been made.
• Infection control: clinical waste was not disposed of in accordance with guidance set out in Health Technical Memorandum 07-01: Safe management of healthcare waste.
• Equipment: items of portable electrical equipment in use, such as electrical heaters or light stands, had not been safety electrical checked.

But we found the following areas of good practice:

• Staff training in mandatory training was up to date.
• The service was visibly clean and mostly un-cluttered and all ultrasound equipment seen had been maintained.
• The service used competent staff to do the scanning who had been appraised.
• If needed service users could be referred to the NHS and staff had a process to follow.
• The service ran to time, with no cancellations.
• The feedback forms we saw were positive about service user experience at the service.
• Staff we spoke with and minutes of meetings we reviewed showed an open culture where the leadership team were accessible and approachable.