25 October 2022
During an inspection looking at part of the service
Our rating of this service improved. We rated it as good.
This was a focused, unannounced inspection. The inspection followed up a previous inspection in June 2022 which had been a focussed, unannounced inspection in response to specific areas of concern. We did not rate the service as we only inspected the key lines of enquiry within the safe and well – led domains.
Following the June 2022 inspection, we served the provider with a Warning Notice under Section 29 of the Health and Social Care Act 2008. The warning notice told the service that they needed to make significant improvements in their governance processes to ensure the quality and safety of services provided. The provider sent the CQC a report with the actions that they were taking to meet the requirements.
At this inspection, the provider had made improvements.
- The service provided mandatory training to staff and all staff were up to date with basic life support training. The service had a process that ensured staff were reminded to renew their training when required.
- The registered manager and staff had completed the relevant training in safeguarding. They had a process in place, which was in line with their policy, which kept women safe, if a safeguarding concern was identified.
- The service managed infection risk well and had implemented more measures to protect service users and staff from infection. The service had robust systems for cleaning of the scanning beds and had removed equipment that we had identified as problematic at the last inspection. The premises and the equipment was visibly clean.
- The design, maintenance and use of facilities, premises and equipment kept people safe.
- The staff completed risk assessments for women using the service. Staff were confident in how they would respond to foetal abnormalities which may be identified or if a women’s health was to deteriorate.
- The service had enough staff to provide a safe service. We were assured that staff had the correct qualifications, competence and experience to complete their roles.
- The records relating to the care and treatment of service users were appropriately completed. Women’s records were stored securely.
- The process for reporting incidents was in place and in line with the services policies. The manager investigated the most recent incident and shared learning with the team. Staff had received training on the duty of candour, and it was evident that their knowledge of this area had improved.
- The registered manager had the skills and abilities to run the service and demonstrated a better understanding of the priorities and issues the service faced. They supported their staff to develop and take on more senior roles.
- The service did not have a specific vision or strategy, but the registered manager and staff identified the services main priority as customer experience.
- The staff felt respected, supported, and valued. The registered manager was aware of equality and diversity in daily work and provided opportunities for career development.
- Leaders operated effective governance processes. Staff were clear about their roles and accountabilities.
- Leaders and teams used systems to manage performance effectively.
However,
- Women’s scan records were not always signed and dated.
- The scheme of delegation still required some work to fully embed. There was some ambiguity around who staff should contact if the registered manager was unavailable.
- The services website had not been updated from the previous inspection and still stated that diagnostic scans were being offered, despite the registered manager being clear that this was not the case.