Cherished Moments

Independent Healthcare Org · West Midlands

Overall Rating
Requires Improvement Last inspected 3 November 2021
Domain Ratings
Safe
Requires Improvement
Effective
Not Yet Rated
Caring
Good
Responsive
Good
Well-led
Requires Improvement

View Full CQC Report

11 must-do actions
3 should-do actions

Must-Do Actions (11)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The service must ensure offensive waste is disposed of in line with national guidance.
Regulation 12(1)(h)
Staff did not always dispose of offensive waste safely. Offensive waste is non-clinical waste that’s non-infectious and does not contain pharmaceutical or chemical substances but may be unpleasant to someone who comes into contact with it. Gloves, aprons and sanitary towels were disposed of as normal waste and this was …
Must Do
Safe
The service must ensure that approved wipes are used for cleaning of the ultrasound equipment as per manufacturer’s recommendation.
Regulation 12(1)(h)
Staff used antibacterial spray to clean the ultrasound equipment. This was not in line with the manufacturer’s guidance on cleaning and maintenance of the ultrasound equipment which recommended the use of approved wipes for cleaning. We could not be assured that the risk of cross-contamination was mitigated.
Must Do
Safe
The service must ensure hand hygiene and environmental cleaning audits are carried out.
Regulation 12(1)(h)
We did not see evidence of infection prevention and control or hand hygiene audits during our inspection.
Must Do
Effective
The service must ensure peer reviews and imaging reports are audited for quality purposes.
Regulation 17(1)(2)(b)
Managers and staff did not carry out a comprehensive programme of repeated audits to check improvement over time. For example, staff did not carry out audits into the quality of ultrasound scanning undertaken and the reports generated. The service didn’t have any arrangements for peer review of scans and reports.
Must Do
Safe
The service must ensure that quality assurance is carried out on the ultrasound equipment.
Regulation 17(1)(2)(b)
Staff did not carry out daily safety checks of specialist equipment. There was no safety checklist for the scanning machine. Staff did not carry out quality assurance on the ultrasound equipment as recommended by the British Medical Ultrasound Society.
Must Do
Safe
The service must ensure a referral pathway for women potentially identified as experiencing mental health crises or acute anxiety is in place.
Regulation 17(1)(2)(b)
Staff didn’t have access to mental health liaison and specialist mental health support if staff were concerned about a woman’s mental health. There was no referral pathway (for example, referral to a single point of contact) for women potentially identified as experiencing mental health crises or acute anxiety.
Must Do
Well-led
The service must ensure there is a governance system in place to ensure referrals made to NHS services are followed up.
Regulation 17(1)(e)
The service didn’t have a system in place to ensure such referrals were followed up. For example, of the 12 incidents recorded which entailed no foetal heartbeat or viable pregnancy detected, no follow up contact was made to seven women.
Must Do
Safe
The service must ensure equipment faults and other safety incidents are reported as incidents.
Regulation 17(1)(2)(a)
Staff did not report incidents relating to equipment breakdown in line with the provider’s policy. For example, staff told us of an incident where a baby’s heartbeat had not been detected due to a fault in the ultrasound device. We reviewed the incident reporting system and no equipment breakdown had …
Must Do
Effective
The service must ensure assurance process are in place to check ongoing competencies of the ultrasound technician.
Regulation 18(2)(a)
The staff were competent for their roles; however, the service didn’t have an assurance process in place to check their ongoing competencies.
Must Do
Effective
The service must ensure all staff are appropriately trained for their role.
Regulation 18(2)(a)
Evidence reviewed during our inspection revealed all competencies were signed on the same day. There was no evidence of staff training start and end dates. We therefore could not be assured staff had undergone the required training to enable them to competently carry out scans.
Must Do
Safe
The service must ensure enhanced Disclosure and Barring checks are carried out.
Regulation 19(1)(a)(2)
The provider didn’t ensure that all staff underwent appropriate checks as required by schedule 3 of the HSCA 2008 (regulated activities) regulation 2014. Not all staff had an enhanced Disclosure and Barring (DBS) checks in place. For example, the ultrasound technician had a standard DBS in place.

Should-Do Actions (3)

Recommended improvements to enhance service quality.

Should Do
Safe
The service should ensure single used pre-filled bottles are used in line with recent guidance.
Regulation 12(1)(h)
Should Do
Responsive
The service should ensure information on how to complain is readily available and accessible to women who use the service and learning from complaints is shared with staff.
Regulation 17(1)(2)(a)(b)
Should Do
Well-led
The service should ensure they have a risk register to monitor and mitigate the risks for the service.
Regulation 17(1)(2)(a)(b)
Location Details
CQC ID: 1-10875835294
Local Authority: Solihull
Region: West Midlands
Inspection Report
Type: Comprehensive inspection
Date: 3 November 2021
Rating: Requires Improvement
Actions: 11 must-do , 3 should-do
AI-extracted 17 Feb 2026