Archived: this is my: Hull Screening Centre

Updated 7 March 2019

this is my: Hull Screening Centre was operated by this is my: limited. It was a private ultrasound scanning service which opened in Hull in 2013. The service primarily served Hull and the surrounding area.

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

• Diagnostic and screening procedures

We conducted a short-announced inspection of the ultrasound, (including 4D meet your baby bond scans) and NIPT testing part of the service on 19 December 2018. The service also offered gene screening for inherited disorders. We did not inspect these services.

We conducted a follow-up inspection on 25 January 2019 because, when we inspected on 19 December 2018, we were unable to view service user records or speak with the lone worker owing to service user demand and because electronic service user records were being used.

The previous CQC inspection of this service was in June 2013. At that time the service met the fundamental standards inspected against.

Updated 7 March 2019

this is my: Hull Screening Centre was operated by this is my: limited. The service was an independent private medical provider offering health screening imaging using ultrasound (use of sound waves to get pictures of the inside of people’s bodies), to self-funding or private medical service users but it also saw NHS service users under contract.

this is my: Hull Screening Centre was situated on the ground floor of a modern purpose-built building that was wheelchair accessible and had ample on-site parking which was free of charge. The main reception was managed by the building operator but service users were directed down a corridor to the service’s office. The service’s office opened into a room which had adequate seating and a desk with a radio playing, lockable low-level storage cabinets, and two further rooms, one of which was the treatment room and the other a room with extra seating. Service users could access toilets and a café in the main building.

The service provided a screening and ultrasound scans for service users aged 17 to 65 in relation to pregnancy (from the earliest stages of pregnancy through to 42 weeks, including endometrial thickness measuring (for women going overseas for fertility treatment)), and non-pregnancy related scans, such as pelvic scans. Also, the service provided what it called ‘4D meet your baby bond scans’.

In addition, it supplied Non-Invasive Pre-Natal Testing (NIPT) (a test used to predict certain conditions in the unborn baby, such as Down’s syndrome), with blood samples taken at the centre and then transported to the Leeds site for onward transportation to a third-party laboratory.

We inspected this service using our comprehensive inspection methodology. We carried out the short-announced part of the inspection on 19 December 2018. We had to conduct a short-announced inspection because the service was only open if demand from users of the service required it. We conducted a follow-up inspection on 25 January 2019 because, when we inspected on 19 December 2018, we were unable to view records of service users or speak with staff owing to demand from service users.

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 previously rated this service in June 2013. At that time the service met the fundamental standards inspected against.

At this inspection we rated it as Good overall.

We found the following areas of good practice:

• Staff training in mandatory training was up to date.

• The service was visibly clean and un-cluttered and all 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 there was a process to follow.

• The service ran to time, with no cancellations.

• The service users we spoke with were positive about their experience at the service.

• The service had a complaints system in place, with low levels of complaints over the last year, and made changes to the service as needed considering feedback from service users.

• The service had a clinical governance process in place to maintain quality which put safety of users of the service first, and had a system for recording and acting on risks.

• Staff we spoke with and minutes of meetings we reviewed showed an open culture where the leadership team were accessible and approachable.

We found a breach of regulation because staff were not trained in consent and mental capacity.

While not a breach of a regulation, we also found the following issues, that the service provider needs to improve:

• The flooring in the treatment room was carpeted: this posed a challenge for infection prevention and control, say, if, when taking blood for a NIPT, there was a spillage of human blood products onto the floor in the treatment room.

• The service was operated by a lone worker: this posed not only a risk to their personal health and safety, if a service user (or their relative) became violent, but also to that of a service user waiting to be seen that deteriorated, while the lone worker was treating another service user.

• The location did not have a written policy for staff to follow to support staff with their obligations in relation to female genital mutilation (FGM) and neither had staff been trained in FGM.

• The location did not have a written policy for staff to follow to support staff in complying with the relevant regulations and associated published guidance around transportation of human blood products from the location to the Leeds location where samples were sent to a laboratory.

• The location did not display any information to inform service users about their right to and how to complain.

• The risk register for the location needed to be reviewed to ensure that it accurately reflected the risks posed at the location.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected the service. Details are at the end of the report.

After the initial inspection in December 2018 and prior to the follow-up inspection in January 2019, the service had already actioned or set in progress to complete, all the improvements we had highlighted above.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)

Updated 7 March 2019

At this inspection we rated it as Good overall.

We found the following areas of good practice:

• Staff training in mandatory training was up to date.

• The service was visibly clean and uncluttered and all 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 there was a process to follow.

• The service ran to time, with no cancellations.

• The service users we spoke with were positive about their experience at the service.

• The service had a complaints system in place, with low levels of complaints over the last year, and made changes to the service as needed considering feedback from service user users.

• The service had a clinical governance process in place to maintain quality which put service user safety first, and had a system for recording and acting on risks.

• Staff we spoke with and minutes of meetings we reviewed showed an open culture where the leadership team were accessible and approachable.

We found a breach of regulation because staff were not trained in consent and mental capacity.

While not a breach of a regulation, we also found the following issues, that the service provider needs to improve:

• The flooring in the treatment room was carpeted: this posed a challenge for infection prevention and control, say, if, when taking blood for a NIPT, there was a spillage of human blood products onto the floor in the treatment room.

• The service was operated by a lone worker: this posed not only a risk to their personal health and safety, if a service user (or their relative) became violent, but also to that of a service user waiting to be seen that deteriorated, while the lone worker was treating another service user.

• The location did not have a written policy for staff to follow to support staff with their obligations in relation to female genital mutilation (FGM) and neither had staff been trained in FGM.

• The location did not have a written policy for staff to follow to support staff in complying with the relevant regulations and associated published guidance around transportation of human blood products from the location to the Leeds location where samples were sent to a laboratory.

• The location did not display any information to inform service users about their right to and how to complain.

• The risk register for the location needed to be reviewed to ensure that it accurately reflected the risks posed at the location.