Baby Ultrasound Clinic Sheffield

The service had been inspected but not rated previously. We rated it as good.

This was a comprehensive, short notice announced inspection to follow up on actions taken since our previous focused inspection in June 2022. At this inspection we inspected the key lines of enquiry within all 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 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 had enough staff to care for women and keep them safe.
• Staff had training in key skills, understood how to protect women from abuse, and managed safety well. 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 service carried out recruitment processes to ensure that staff employed were recruited safely.
• The service managed infection risk well and had implemented more measures to protect service users and staff from infection. The service had implemented processes and systems, and staff had clear responsibilities for cleaning and checking the environment and equipment. The premises and all equipment were visibly clean.
• The design, maintenance and use of facilities, premises and equipment kept people safe.
• Staff identified and acted quickly upon patients at risk of deterioration. They completed risk assessments for women using the service. Staff were confident in how they would respond to unexpected events such as foetal abnormalities which may be identified or if a woman’s health was to deteriorate.
• The service kept good care records.
• The service managed safety incidents well and learned lessons from them. The process for reporting incidents was in place and in line with the service’s policies. The manager investigated the most recent incident and shared learning with the team, and it was evident that their knowledge of this had improved.
• Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to women, families and carers.
• The service planned care to meet the needs of local people, took account of women's individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait for their results.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. 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 responsibilities.
• Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported, and valued. They were focused on the needs of women receiving care. The registered manager understood 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:

• Although incidents were recorded, there was nowhere in the incident book to complete the severity and rating of the incident and therefore the provider’s adverse incident reporting policy was not followed fully.
• The service should consider making some of their documentation more detailed. The risk register would benefit from a review date, a timescale for when actions would be completed, and the location associated with the risk being added. The service should also consider including a severity rating on the incident log, in line with the adverse incident reporting policy.
• The service did not have facilities to meet the needs of people with sight or hearing problems. There was not a hearing loop and no information available in accessible formats.
• The service did not have information leaflets available in different languages, staff understood the needs of their local population and told us information from the website could be translated when necessary.

We rated this service as good because it was safe, effective, caring, responsive, and well led.