4 September 2019
During a routine inspection
The Marlow Clinic (The Baby Scan Studio) is operated by CS Partners Medical Limited. The service provides diagnostic pregnancy ultrasound, gynaecological and fertility scans. The service also provides scans for small body parts (testes and thyroid) ultrasound, leg vein assessment for deep vein thrombosis and abdominal ultrasound scans. The service offers non-invasive prenatal testing (NIPTs) to self-funding women predominantly across Berkshire, Buckinghamshire and Oxfordshire but would accept women from across the UK. NIPTs can be used to assess if a woman’s foetus is at a higher risk of having certain genetic and chromosomal conditions, using a venous blood sample taken from the pregnant woman. It is referred to as non-invasive because it does not involve the insertion of a needle into the woman’s abdomen or cervix, as is the case with more invasive testing, where cells are taken from the amniotic sac or placenta.
The registered manager also runs an ultrasound clinic in Colchester and another clinic at an independent hospital in Oxford. They work alongside a consultant to provide consultations and ultrasound scanning. The equipment is maintained by CS Partners Medical Limited.
The Marlow clinic (The Baby Scan Studio) provides diagnostic imaging for patients aged 17 years and over. It is registered with the Care Quality Commission (CQC) to provide the regulated activity of diagnostic and screening procedures. It has one ultrasound machine with one waiting area.
We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 4 September 2019. We gave staff two working days’ notice that we were coming to inspect to ensure the availability of the registered manager and clinics.
To get to the heart of patients’ 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.
Services we rate
We have not previously inspected this service. At this inspection we rated it as Good overall.
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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 and treatment.
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Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
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The environment was appropriate and met the needs of the range of patients who accessed the service, including toys for children to play with whilst waiting for parents’ appointments and the service controlled infection risks well.
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Staff completed risk assessments for each patient and removed or minimised identified risks. They created records that were accurate and detailed, and staff kept these accessible and secure. The service effectively managed risks and could cope with both the expected and the unexpected.
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The service improved service quality and safeguarded high standards of care by creating an environment for good clinical care
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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, kind and engaged well with patients and their families.
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Patients could access services and appointments in a way and a time that suited them. The service used technology innovatively to ensure patients had prompt access to ultrasound scans.
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Managers promoted a positive culture that supported and valued staff. Staff reported their team worked well together and staff trusted and respected each other.
However, we also found the following issues that the service provider needs to improve:
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Although the service had policies that were current, and version controlled not all policies evidenced the latest national guidance.
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The service’s safeguarding policy did not refer to children’s safeguarding processes nor did it reference key children’s safeguarding concerns for example, female genital mutilation and child sexual exploitation. The reception staff had not received training in children’s safeguarding processes.
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Office staff did not have annual appraisals, for the discussion of performance and development.
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The service did not have the proper equipment to safely clear any blood spillages.
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The registered manager had not completed Disclosure and Barring checks on all members of staff employed that required the check.
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The ultrasound machine was not password protected and therefore patient data was at risk of unauthorised access.
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 two requirement notice(s) that affected diagnostic and screening services. Details are at the end of the report.