PAMS 3D & 4D Baby Imaging is operated by Mrs Punam Kapur . The service provides ultrasound baby imaging for pregnant women from the gestation of six weeks. This includes, four dimensional (4D), three dimensional (3D) and two dimensional (2D) scans starting from six weeks as reassurance, gender scans from 16 weeks, baby growth scan from 16 weeks, “baby bonding” scans from 34 weeks and keepsake scans. The service also carries out fertility scans to assess reproductive capacity and pelvic scans to examine female reproduction organs and help monitor ongoing gynaecological problems.

We inspected this service using our comprehensive inspection methodology. We carried out the short notice announced part of the inspection on 18 December 2018. On the day we visited the service, there were no women booked for a scan and we did not observe any scans. However, following the inspection we spoke on the telephone with four women who had used the service.

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.

The only service provided at this location was ultrasound scanning.

Services we rate

This was the first time we have rated this service. We rated it as Good overall.

We found areas of good practice:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.

• The service controlled infection risk well and they had suitable premises and equipment and looked after them well.

• Staff assessed risks to women, they kept clear records and asked for support when necessary.

• Staff kept detailed records of appointments, referrals to NHS and other services and completed informed consent documents.

• 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.

• The service provided care and treatment based on national guidance and evidence of its effectiveness.

• The service checked to make sure staff followed guidance through the process of local audit.

• Managers monitored the effectiveness of care and treatment and used the findings to improve them.

• Staff worked closely with other healthcare professionals in the NHS, including early pregnancy assessment units, foetal medicine and GPs to provide a seamless treatment pathway for women.

• Staff treated women with compassion and kindness. Women who used the service told us that staff respected their privacy and dignity, and supported their individual needs.

• Women who used the service told us that staff provided them with emotional support to minimise their distress

• Staff involved women and those close to them in decisions about their care and treatment. This was confirmed by the women who used the service.

• The service planned and provided services in a way that met the needs of local people.

• The service had suitable premises and facilities to meet the needs of the women who use the service.

• The service took account of women’s individual needs.

• People could access the service when they needed it.

• The registered manager of the service had the right skills and abilities to run the service providing high-quality sustainable care.

• The service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

• The service systematically improved service quality and safeguarded high standards of care by creating an environment for excellent clinical care to flourish.

• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

  However, we also found the following issues that the service provider needs to improve:

• Complaints were not being reported in line with the service’s complaints policy.

• The service lacked systems and processes to ensure that policies and procedures were reviewed and implemented accordingly.

• The service had limited systems in place to identify, monitor and regularly review risk.

  Following this inspection, we told the provider that it must make improvements, even though a regulation had not been breached, to help the service improve.

• The service should ensure that they have systems and processes place to review policies and guidelines are up-to-date and current.

• The service should ensure that complaints are recorded in line with the complaints policy.

• The service should ensure staff meetings are minuted, and action logs documented.

  Amanda Stanford

Deputy Chief Inspector of Hospitals