Date of provider / location engagement meeting

27th August 2020 09:30-10:30

Telephone engagement (converted from a visit due to Covid-19).

Provider (including CRM ID)

Ultrasound Baby Face Ltd 1-1616736842 (Provider)
Ultrasound Baby Face 1-5208370979 (Location)

Sector/s Independent Health
Cross Directorate No
Relationship Owner Cathy Poulton
Registered Manager Thomas Moore

Thomas Moore - Registered Manager
Cathy Poulton – Relationship Owner, Inspector
Odette Coveney – Inspection Manager

Summary / Provider overview Please provide a summary of the Ultrasound Baby Face service, including opening hours.
Stakeholder contact details
PHE, CCGs, Healthwatch, Other stakeholders:
Please detail any stakeholders and their contact details.
Actions from previous engagement meeting

No previous engagement meetings due to dormancy February 2019 – January 2020 and dormancy 28th March 2020 to present.
Initial engagement meeting prior to provider request to lift the dormancy and restart the regulated activities 5th September 2020.

CQC updates
From time to time relationship leads will be asked to seek feedback from providers on a specific theme. This could relate to CQC thematic reviews or a specific issue affecting on the sector, eg: shortage of nurses
  • Overview of the role of CQC Inspectors and the CQC structure in regulating against the Health and Social Care Act, 2008. The maintenance of portfolios, CQC intelligence, and the plan for ongoing provider engagement with CQC relationship owner.
  • Interim Head of Hospital Inspection (HOHI), Mandy Williams. HOHI will be changing to Catherine Campbell, date of change TBC Autumn 2020
  • CQC website – sign up to the CQC newsletter and provider bulletin to stay updated with changes and publications. Provider community also available. Please see here for details.
  • Mandatory reporting and notifications explained (see Reg 18). For example, reporting items that affect service delivery, safeguarding issues, theft of equipment and police incidents.
    Please see the following links for further details: here
  • Please see the PDF document ‘guidance for providers on meeting the regulations’ as this features all the regulations.
  • Inspection reports for baby scanning services – see CQC website
  • Strategy 2021: Smarter regulation for a safer future. We want to be a world-class regulator able to drive improvements in how people experience health and care services, working towards a safer future. To achieve this vision, we are developing a bold new strategy from 2021 that builds on our successes and values and keeps our purpose central.
  • Innovation and inspiration: examples of how providers are responding to coronavirus (COVID-19)
  • Emergency Support Framework
  • Closed cultures. The CQC has published new guidance for inspectors on closed cultures. A closed culture is a poor culture in which people are at an increased risk of harm, including abuse and breaches of human rights.
    Update: Our work on closed cultures
  • An article was published in the Sunday Times on the 19 th  July about potential risks in baby scanning services, which, if substantiated, would indicate women using services are being placed at risk. There has also been an article in the BMJ which raises potential similar concerns.
    CQC has therefore developed additional questions specific to baby scanning services to help identify if there are any concerns in services provided at individual locations, or if the potential risk is more widespread across larger numbers of providers in this sector. Please see ‘quality and performance overview’ section for the additional questions and subsequent responses.
Covid-19 Update: Additional acute independent healthcare provider engagement questions during Covid-19 (see embedded questions).
1. Has your service been operating during the period of lockdown (since March 23rd 2020)?
  1. If yes, has this been for the whole period or did you close and resume services?
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2. Have changes been made in the location to the layout/environment in response to the Covid-19 pandemic?
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3. Is the service able to access adequate supplies of appropriate PPE for the location?
  1. Do you anticipate any problems in the future?
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4. How is clincal waste disposed?
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5. Are protocols in place for assessing patients for Covid-19?
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6. Are protocols and guidance in place for assessing and testing staff for the presence or absence of Covid-19?
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7. How are appointments spaced out to allow both adequeate time to assess and image the patient and then clean in line with CV19 guidance?
  1. What guidance do you follow?
  2. How do you ensure clinics are not over booked at any one time/during this period?
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8. Are there sufficient numbers of suitably competent staff to provide appropriate care and treatment?
  1. Have staff been advised of PPE ‘donning’ and ‘doffing’ procedures?
  2. Are mitigation plans in place in response to changes such as staff sickness levels?
  3. Are staff adequately risk assessed and placed in appropriate environments to protect their health and safety, including BAME staff?
  4. Is there a clinical lead and how do staff access them or other appropriate healthcare professional for support?
  5. How is the quality of the scans and accuracy of identifying any problems or anomaly, such as absent fetal heartbeat or the potential presence of spinal cord defects, monitored in the service?
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9. What do you do if you identify a suspected anomaly during the scan, and how is this followed up?
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10. Are women given appropriate information about the scan, its limitations and associated potential risk including any risks of attending the scan during Covid-19?
  1. If the woman is to have a transvaginal scan, how is informed consent obtained?
  2. Are women informed to still attend their routine NHS scans as part of their maternity pathway?
  3. Is the woman’s consent to care and treatment always sought in line with legislation and guidance; and is consent obtained to share information with the woman’s GP or other healthcare professional e.g. midwife if necessary, and prior to the scan being conducted?
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11. Has your service been operating during the period of lockdown (since March 23rd 2020)?
  1. If yes, has this been for the whole period or did you close and resume services?
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12. What support is made available to the women when receiving the scan, are they given additional support and signposted to other services which may provide counselling services or support?
  1. Do all staff having contact with patients and their families have appropriate levels of safeguarding training?
  2. Do all staff having contact with patients and their families have enhanced adult’s and children’s DBS?
  3. Do staff know how to raise a safeguarding concern about a patient who has attended a scan?
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Provider wide quality update - Discussions by key question
This field includes areas that are location/provider level rather than specific to a core service.
Safe -Safe means that people are protected from abuse and avoidable harm.
Safety (including Infection) track record e.g. National patient safety alerts & relevant actions & cascade of information
  • Legionella risks during the coronavirus outbreak – guidance available from the Health & Safety Executive, as shared by Ted Baker on the provider bulletin 7/8/2020.
Specific data from National Systems on Safety
(including but not limited to)
  1. Never events and serious incidents
  2. Coroner rule 28 letters
  3. Rise/change in infection rates
No information of concern received by the CQC.
(any issues which have required action by the location, including outcomes)
e.g. FGM, domestic abuse, any changes to safeguarding policy and procedures, confirmation of the updated position on safeguarding training (Intecollegiate guidance).
Duty of candour
(notifiable incidents under legislation)
(including agency use)
Please confirm the current position and assurance around suitable numbers of competently trained staff to meet the service need. Please advise of any staff disciplinary issues either currently or since the service reopened in January 2020. Please provide the structure chart, if available.
Effective -By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.
Update on national guidance implementation
e.g. NICE/Royal Colleges
Are there any current priorities for the location or within the national organisation at this time.
Patient outcomes Indicators that are better or worse than expected
Indicators showing improvement & decline
Mental Health Act Any cases relating to this legislation and any actions required by the service. Confirmation that required documentation is completed. Confirmation of the current position in respect of staff training.
Practising privileges AAssurance of competence & number of staff this relates to – any staff also working within the NHS?
Caring -By caring, we mean that the service involves and treats people with compassion, kindness, dignity and respect
Patient survey results
(examples of good practice)
Process of obtaining patient feedback and current status. Patient engagement process and examples.
Responsive -By responsive, we mean that services meet people’s needs.
Service Planning Business plans, strategic aims and service capacity.
Complaints including trends and themes Complaints results: number, trends and learning identified. Parliamentary and Health Service Ombudsman referrals
Well led -By well led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.
Governance framework for quality, performance and risks Please provide a copy of the current risk register with date the risk was identified and review date, if available. Please provide a summary of any audits undertaken or planned
Executive directors/senior staff/registered managers Please can you confirm the current position.
Review of the current registration status Registration certificate dated 29/03/2019.
Please confirm the attached registration certificate is correct.
Staff engagement How is staff engagement monitored? Information if performance is better/worse/improved/declined.
Potential issues of media interest
Freedom of Information Act 2000
Section 45 Requests
Please add a summary of any requests made.
Any otherbusiness
  • Portfolio management (CQC)
  • Registered manager registration (CQC)
Date of engagement meeting: …February 2021 (Telephone/Visit).