Meet The Baby

Independent Healthcare Org · North West

Overall Rating
Requires Improvement Last inspected 31 May 2022
Domain Ratings
Safe
Inadequate
Effective
Not Yet Rated
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

View Full CQC Report

13 must-do actions
9 should-do actions

Must-Do Actions (13)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Well-led
The provider must ensure that there are arrangements in place for all staff to undertake annual mandatory training.
Regulation 18
Staff had training in key skills but the provider did not have details of what ongoing arrangements were in place to deliver annual mandatory training courses going forward.
Must Do
Safe
The provider must ensure that there is a member of staff with level three children’s and adult safeguarding on site when the premises are open.
Regulation 13
There was not always a person trained to level three in adult and children’s safeguarding on site when the clinic was open.
Must Do
Safe
The provider must ensure that all staff have a good understanding of infection prevention and control practice to ensure that the service is run safely, for example, disposal of clinical waste, handwashing and storage of cleaning chemicals.
Regulation 12
The service did not always control infection risk well. Staff did not manage clinical waste safely.
Must Do
Safe
The provider must ensure that all clinical waste, particularly offensive hygiene waste such as personal protective equipment (PPE), couch roll and clinical wipes, is disposed of safely in clinical waste bins with foot pedal or no touch operation. The bins should be stored in the same room where clinical waste needs to be disposed of so that clinical waste is not being carried through waiting areas of the clinic.
Regulation 15
Clinical waste was not disposed of safely. The manager was unaware that used PPE was clinical waste and it was not disposed of safely. There was a swing bin in the stockroom that had a yellow clinical waste bin liner. The bin was not a clinical standard waste bin that …
Must Do
Safe
The provider must ensure that clinical waste stored outside for collection is in a lockable bin or store.
Regulation 15
There was no lockable clinical waste bin that could be left outside for the collection of clinical waste.
Must Do
Safe
The provider must ensure that hand washing facilities are available in the scanning room.
Regulation 15
There were no hand washing facilities in the scanning room. The only hand washing facilities were in the toilet area.
Must Do
Safe
The provider must ensure that all furniture in the premises is constructed from, or upholstered in, a wipeable material.
Regulation 15
Furnishings were unsuitable in the waiting area where they were not covered in a wipeable material and were visibly dirty.
Must Do
Safe
The provider must ensure that hazardous cleaning chemicals are kept in a locked cupboard in accordance with the relevant regulations.
Regulation 15
Hazardous cleaning products, although stored in the stockroom, were not kept in a locked cupboard in accordance with the Health and Safety Executive Control of Substances Hazardous to Health (COSHH) guidance.
Must Do
Safe
The provider must ensure that there are appropriate measures in place to check the age, identity and key pregnancy information and history of the woman.
Regulation 12
The service did not always have appropriate arrangements in place to assess and manage risks to women and their foetus. Women were not asked to bring their NHS pregnancy notes with them to the scan. Women were not asked to complete a pre-scan questionnaire about their pregnancy history. Women were …
Must Do
Safe
The provider must ensure that appropriate procedures are in place in the event of a medical emergency.
Regulation 12
We were not assured that staff knew what to do and would act quickly when there was a medical emergency. We were not assured that all staff knew what to do in the event of a medical emergency.
Must Do
Effective
The provider must ensure that they obtain the appraisals for Sonographers working at the service whose substantive post is elsewhere in the NHS or another provider or that a formal appraisal process and competency framework is developed where these cannot be supplied.
Regulation 18
They did not have processes in place to carry out or review appraisals for sonographers working in the clinic. There was no formal process for appraisal or supervision of the sonographer, and they did not have a substantive post in the NHS so were not being appraised elsewhere. There was …
Must Do
Well-led
The provider must ensure that there are formal monitoring processes in place to review quality assurance and clinical safety.
Regulation 12
There was no formal monitoring in place to review quality assurance and clinical safety. The manager undertook financial audits but no clinical audits. The service had no formal audit programme in place to review quality assurance and clinical safety.
Must Do
Responsive
The provider must ensure that there is access to independent interpreters to assist women whose first language is not English or who may have a hearing impairment to ensure that a relative does not act as an interpreter where there may be a safeguarding concern.
Regulation 9
The service did not have information leaflets available in languages spoken by the women and local community. The service did not have access to an independent translation service. The service did not have a hearing loop for women with hearing impairments or access to information in braille for women with …

Should-Do Actions (9)

Recommended improvements to enhance service quality.

Should Do
Safe
The provider should ensure that all staff have undertaken training in female genital mutilation (FGM).
Regulation 18
Should Do
Safe
The provider should ensure that there is an appropriate decontamination policy and relevant training has been undertaken by all staff involved in using and/or decontaminating any transvaginal probe before this is brought into use.
Regulation 15
Should Do
Safe
The provider should ensure that regular hand hygiene and infection prevention and control audits are carried out on staff undertakings scans to ensure compliance with infection control and hygiene techniques.
Regulation 15
Should Do
Safe
The provider should ensure that the couch in the scanning room is serviced to assure that it remains safe to use.
Regulation 12
Should Do
Safe
The provider should consider asking women whether they have a latex allergy before they attend for a scan in order that appropriate measures can be taken to prevent them from coming into contact with latex in the clinic.
Regulation 12
Should Do
Safe
The provider should ensure that there is a “pause and check” safety checklist displayed in the clinic as an aide memoire to staff to confirm identity and consent before any procedure is undertaken.
Regulation 12
Should Do
Effective
The provider should ensure that appropriate further consent procedures are in place before transvaginal scans are introduced as a service.
Regulation 11
Should Do
Caring
The provider should ensure that the privacy and dignity of women is maintained at all times.
Regulation 10
Should Do
Well-led
The provider should have policies and procedures in place in line with regulated activity, including recruitment. The provider should ensure that all policies and procedures have review dates so that updates can be tracked.
Regulation 17
Location Details
CQC ID: 1-10409734956
Local Authority: Warrington
Region: North West
Inspection Report
Type: Comprehensive inspection
Date: 31 May 2022
Rating: Requires Improvement
Actions: 13 must-do , 9 should-do
AI-extracted 17 Feb 2026