Ultrasound Diagnostic Services

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally and were free from bullying or harassment. Staff understood their roles and responsibilities.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision and strategy. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders and staff shared a vision of delivering an excellent, patient-centred service that inspired confidence and trust. This was measured through positive patient feedback, complaints, and the provision of timely scan reports that patients could take to their referring doctors. While the service did not have a formal written strategy, staff described the overarching aim as providing a high-quality, compliant, and accessible service.

Equality, diversity, and inclusion (EDI) was promoted through mandatory training for all staff. Leaders provided an inclusive service for both staff and patients accessing the service. For example, provision was made for those with severe mobility issues to be seen on the ground floor of the building rather in the service’s basement location. Referrals were accepted both from the UK and overseas, reflecting the service's inclusive approach.

Staff and leaders engaged with both referrers and patients to shape aspects of the service. For example, the service took into account a referrers’ audit which gathered feedback on the quality of service and highlighted areas for improvement, such as increasing gynaecology appointment availability and enhancing signage.

The service also engaged with referring clinicians at networking events, including a "cocktail evening," fostering collaboration and feedback opportunities. A patient user group was consulted when designing the service's website, ensuring it appealed to a diverse audience. Leaders intentionally avoided a medicalised tone in the website’s imagery and content, aiming to make it more inclusive and reflective of overall wellbeing rather than focusing solely on early pregnancy.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leadership was described as inclusive, with staff feeling supported and empowered to manage day-to-day operations effectively and implementing contingency plans. For example, if IT systems failed, staff used pre-prepared paperwork to record patient details and transferred these onto the database once systems were restored.. There were escalation processes in place to support staff. For example, if the registered manager was unavailable, staff could contact one of the consultant partners, for advice or support. The consultants were on-site for their weekly clinics, but were accessible via telephone, email, or messaging apps for advice or decision-making.

Leaders worked collaboratively with partners and there were regular partners’ meetings, primarily conducted remotely, with agendas and minutes recorded. Ad-hoc meetings were arranged as needed, such as to discuss pre-eclampsia screening initiatives. Staff were encouraged to contribute ideas during these discussions, fostering a collaborative and inclusive environment. The service also held annual general meeting to review progress and address strategic goals. However, team meetings were held on an ad hoc basis, meaning there were missed opportunities for learning for example sharing identified areas for improvement following investigations of complaints or incidents.

Staff were provided with opportunities for development and training was supported by the service. For example, a sonographer was scheduled to complete a health and safety course, with time allocated within their rota. Regular appraisals informed staff development and were used to provide constructive feedback. Staff described a positive workplace environment with strong peer support. However, it was noted that communication could be challenging due to the part-time presence of some sonographers, requiring careful coordination and follow-up. This meant some staff may not be aware of any changes made in the service or recently circulated information. Following the inspection the registered manager informed us there was a group chat on a mobile application where key information was shared. However, there was no assurance that all staff would access this or review the information shared on a regular basis.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The service had governance arrangements in place to manage performance and risks, supported by audits, data security protocols, and a structured complaints system. Clinical risks were identified and managed through regular audits of consultants and sonographers’ work. Findings were reviewed and any concerns were promptly addressed, with feedback provided directly to the individuals involved. A recently implemented health and safety system was being used to consolidate risk assessments, although a centralised risk register was not in place, meaning the provider may not have oversight of all risks and the actions being taken to mitigate these. Complaints were handled in line with the service’s complaint’s process. They were acknowledged within 48 hours and investigated by consultants, who communicated directly with patients, either inviting them back for a follow-up or resolving issues via correspondence. For example, a patient dissatisfied with a specific sonographer was contacted, and the matter was resolved with a rescan and appropriate follow-up with the referring consultant. All complaints were logged and progress resolving these documented, ensuring a clear audit trail. It was unclear how feedback and learning from complaints was shared with staff. Following the inspection the registered manager informed us feedback was given to staff directly.

Data security was robust. Patient data was stored on a secure server with daily backups undertaken. Communication with external bodies, such as GPs, and insurers, was conducted using encrypted email systems. Mandatory data protection training ensured staff understood and adhered to confidentiality standards.

The service held regular partners' meetings, which were minuted and included discussions on financial performance, risk management, and strategic planning. Financial sustainability was monitored quarterly, with measures in place to address fluctuations in patient numbers. Leaders stated the business remained financially viable and adaptable to challenges, such as reduced demand post-COVID-19.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.