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Index

1. Provider Details

1.1 Please provide details of your location. Please refer to the accompanying guidance to help you determine your location.

Registered location name:
Registered ID number:
Registered location address:
Website address (if applicable):

1.2 Details of person responsible for completing this form

Name:
Job Title:
Contact telephone:
E-mail address:

1.3 Date of information extract

Please enter the date at which you ran the data from your systems (DD/MM/YYYY):

1.4 Which of the following describes your location Please identify from the list below:

1. A stand-alone purpose-built diagnostic or screening facility
2. A room (rented/leased or borrowed) within a building belonging to another healthcare provider registered with CQC
3. A mobile service that travels to more than one place to deliver services
4. Services provided from satellite units

1.5 Please provide details of the registered manager and nominated person. If you know that the Registered Manager and/or the nominated person will be changing in the next three months, please advise us of the changes including dates.

Role Name of person Details of changes before the inspection visit, if any
Registered Manager
Nominated Person

1.6 Changes to current regulated activities

Do you plan to make any changes to the regulated activities you are registered with us for, before the inspection visit?

If Yes to making changes to regulated activities, please also tell us what are these changes and when do you plan to make them?

Planned change Regulated activity Timescale

1.7 Statement of Purpose

Please provide an electronic copy of your up-to-date Statement of Purpose with this completed document:

Filename for the Statement of Purpose Contact for the Statement of Purpose

If you know that your Statement of Purpose as it applies to your registration will change before the inspection visit, please send us an electronic copy of the new version as soon as this becomes available

2. Diagnostic/screening services provided and patients treated

2.1 Please provide an overview of the history of the service provided at the location:

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2.2 Please specifiy all services you provide at your locations (Eg, 3D/4D scans, Diagnostic screening, NIPTS Tests etc:

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2.3 Please specifiy which age groups you provide services to, and how many you have seen in the past twelve months of each category:

Under 16 16-17 18 - 35 35 and above
Provide Services?
Number seen

2.4 Service overview

1. If you provide your service from a fixed location please provide an overview of the layout of the location

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2. if you provide any of your services from satellite units, please provide an overview of these facilities (these should be facilities which you manage and operate):

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2.5 If you have seen NHS funded patients in the last 12 months, who are your main NHS commissioners?

Service Commissioner Commissioner Address Key Commissioning contact Reason for transfer to you Expected annual volume Type of modality Location/ site detail

3. Additional service information

3.1. Have you out sourced any part of the regulated activity to a 3rd party? If ‘yes’ please provide details below:

Outsourced service Service provider

4. External reviews and investigations

4.1 Has your service been the subject of an external review or investigation in the last 12 months, please specify your reporting period from:

Date from: Date to: Yes/ No
Name of review or investigation Commissioned by Date completed Report Available Location/ site detail

5. Staff details

5.1 Please describe how you determine staffing across your service to ensure it is safe and effective:

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5.2 Please provide details of the current number of staff you directly employ for the service

Staff type WTE Number Headcount –Full time contract Headcount –Part-time contract Headcount –Zero hours contract

5.2 Please provide details of the current number of staff you directly employ for the service

Staff type The number of vacancies WTE The number of vacancies - headcount The number of staff who have joined the service The number of staff who have left the service

5.4 Please provide details of your use of bank and agency staff, and also the rate of staff sickness in the last three months for staff you directly employ:

Staff type Use of bank staff – the number of shifts worked in the last 3 months: Use of agency staff – the number of shifts worked in the last 3 months: Sickness – the average rate of sickness (%) absence over the last three months

5.5 Please describe the induction and training you provide to bank or agency staff:

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5.6 Please provide details of your rates for appraisal and professional registration (if appropriate) of the staff you directly employ:

Staff type The number of current staff (headcount) employed for more than 12 months In the last 12 months the % of these staff who have received an appraisal In the last 12 months the number of staff who have had their professional registration checked (if appropriate) In the last 12 months the number of staff who have been revalidated

5.7 Staff training

1. Please provide the current number of healthcare professionals you directly employ for the service:

2. Please provide details of the healthcare professionals employed and their relevant training:

Name Role Relevant training to perform ultrasound

3. If there are no healthcare professionals employed by the service, please describe how required training is delivered to perform diagnostic ultrasound:

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6. Safe

6.1 Please describe how you ensure the service you provide is safe:

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6.2 Perinatal mortality

1. Have you had any incidences of detecting foetal death in the last 12 full months? Please specify your reporting period:

Date from: Date to: Yes/ No Total number:

2. What is your process in the instance of detecting perinatal death?

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6.3 Never events and serious incidents

Date from: Date to: Number of Never events

2. Please provide a summary of each never event:

Date Type of never event The actual degree of harm Location/ site detail

3. How many ‘serious incidents’ have occurred in your service in the last 12 full months? Please specify your reporting period:

Date from: Date to: Number of SIs

4. Please provide a summary of each serious incident

Date Type of serious incident The actual degree of harm Location/ site detail

6.4 Duty of Candour

1. How many duty of candour notifications were made in the last 12 months? Please, specify your reporting period, and the process within the organisation for determining whether or not a trigger has been reached:

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6.5 Safeguarding

1. Who is/are the service lead(s) for child and adult safeguarding?

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2. Safeguarding training (Children):

What proportion of staff involved in the care of patients aged under 18 are trained to Safeguarding Level 3?
What proportion of staff involved in the care of patients aged under 18 are trained to Safeguarding Level 2?
What proportion of staff involved in the care of patients aged under 18 are trained to Safeguarding Level 1?

3. Safeguarding training (Adults):

What proportion of staff involved in the care of adult patients are trained to Safeguarding Level 2?
What proportion of staff involved in the care of adult patients are trained to Safeguarding Level 1?

6.6 Cleanliness, infection control and hygiene

1. Have you had any incidences of a healthcare acquired infection in the last 12 full months?

If yes, please provide further details:

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2. Please provide details for the person who carries out the following role:

Role: Name Work contact telephone number Work contact email address
Infection control lead

6.7 Records:

1. How does the location ensure that any relevant information from a patient's visit is integrated into their hospital record and/or communicated to their GP as appropriate?

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6.8 Assessing and responding to patient risk

1. What are your processes if you determine any risks with the foetus or foetal abnormality?

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6.9 Medical staffing:

1. Please describe how you ensure access to expert medical advice is available when required:

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7. Effective

7.1 Please describe how you ensure the service you provide is effective:

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Competent staff

7.2 How are you assured that staff are competent – and continue to be so – to carry out their duties effectively?

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8. Caring

8.1 Please describe how you ensure the service you provide is caring:

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Compassionate care

8.2 Please describe how you collect feedback from patients treated about their experience:

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8.3 Please describe if you offer or arrange any counselling services for people who may have received information from yourselves (for example in relation to a NIPTS test or in case or foetal abnormality):

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9. Responsive

9.1 Please describe how you ensure the service you provide is responsive

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9.2 Meeting people’s individual needs

1. Please describe how services are tailored towards the different patient groups that make use of your service:

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9.3 Access and flow

1. Please describe how you manage a new enquiry or referral for admission to the service, including when you have no capacity:

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2. Please describe how you prioritise referrals for procedures/examinations to the service when you have a waiting list:

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9.4 Cancelled examinations

1. Have you cancelled any planned examinations for a non-clinical reason in the last 12 months? Please specify your reporting period

Date from: Date to: Total number

Of these:

2. How many were due to a machine breakdown or other equipment failure?
3. If applicable, how many were due to vehicle breakdown?
4. What was the most frequent reason for cancellation?

9.5 Delayed appointments/procedures/examination

1. Have you delayed any planned appointments for a non-clinical reason in the last 12 months? Please specify your reporting period

Date from: Date to: Total number

Of these:

2. How many were due to a machine breakdown or other equipment failure?
3. If applicable, how many were due to vehicle breakdown?
4. How many were due to staffing issues (sickness/vacancies)?
5. What was the most frequent reason for delay?

9.6 Number of compliments and complaints

Number of compliments

1. How many written compliments did you receive in the last 12 months? Please specify the reporting period:

Date from: Date to: Total number

Number of complaints

2. How many complaints did you receive in the last 12 months? Please specify the reporting period:

Date from: Date to: Total number

Of the complaints received:

3. How many did you manage under your formal complaints procedure?
4. How many did you uphold?

9.7 What processes and information are in place for patients and relatives to raise concerns or make formal complaints?

Please describe what methods are in place to resolve complaints before they become formal?

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Responsibility for complaints

9.8 Please provide the name and job title of the individual(s) responsible for overseeing the management of complaints at the location:

Name Role / job title Responsibility in relation to complaints

10. Well led

10.1 Please describe how you ensure the service you provide is well led:

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Governance, risk management and quality measurement

10.2. Who is the lead for governance and quality monitoring?

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Public and staff engagement

10.3. Please describe examples of how services have been changed and improved as a direct result of the views and experiences of people using the service:

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Innovation, improvement and sustainability

10.4 Please describe any other forms of improvement, innovation or sustainability issues within this service:

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