Miracle Inside UK Ltd is operated by Miracle Inside UK Ltd.
We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 29 March 2019. Our inspection was unannounced (staff did not know we were coming).
To get to the heart of service users’ experiences of care and treatment, 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.
We rated this service as Good overall and found the following areas of good practice:
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The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care.
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Managers appraised staff’s work performance annually and checked to make sure staff had the right qualifications and professional registration for their roles.
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The environment was appropriate and met the needs of the range of people who accessed the service.
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The service provided care and treatment based on national guidance and could evidence its effectiveness.
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Women could access services and appointments in a way and at a time that suited them.
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The service treated concerns and complaints seriously. The registered manager completed comprehensive investigations and shared lessons learnt with all staff.
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Staff were caring, compassionate, and kind, and engaged well with women and their families.
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The service took account of service users’ individual needs.
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Managers promoted a positive culture that supported and valued staff. Staff reported that their team worked well together, and they trusted and respected each other.
However, we also found the following areas the service provider needs to improve:
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The service did not control all infection risks effectively.
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Managers did not provide evidence that they monitored the effectiveness of care and treatment and used the findings to make improvements.
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Managers did not provide evidence that they evaluated images to ensure they were of good quality.
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The service did not collect, analyse, manage, and use information to support all its activities.
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The service had not completed a risk register and did not evidence the management of risks, for example, looking after children during procedures.
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Some policies and procedures were not dated and were not specific to this organisation.
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Following this inspection, we told the provider that it should make some improvements, even though no regulation had been breached, to help the service improve. Details are at the end of the report.
Ann Ford
Deputy Chief Inspector of Hospitals (North)