18 August 2022
During a routine inspection
We have not previously inspected the service. We rated it as requires improvement because:
• Staff did not all have required training in key skills, including safeguarding training.
• The provider did not have a robust recruitment process because two references and other information required under Schedule 3 was not obtained for locum staff.
• The provider and staff did not have an effective audit system in place to monitor and improve the service.
• Staff did not dispose of clinical waste in line with guidance. Staff did not have up to date guidance around the use of ultrasound gels.
• There were no peer reviews or audits of scan images and reports. Sonographers scans and scan documentation should be peer reviewed and audited. Good practice states peer reviews should look at the quality of the report and image and check when a referral was needed, that it had been made to the appropriate people.
• There were no staff meetings or governance meetings to enable discussion and review around risks and trends.
However:
- The service had enough staff to care for women and keep them safe. Staff understood how to protect women from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to women, acted on them and kept good care records.
- Staff provided good care and treatment. 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 told us they could access the service when they needed it, although this was dependent on the availability of the sonographer and did not have to wait too long for their results.
- 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. Staff were clear about their roles and accountabilities. The service engaged well with women and the community to plan and manage services.