Peninsula Hub Also known as Peninsula Ultrasound Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Quality Statement Score: Your judgement of the quality and safety of the topic area

1. We scored the service as 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Safety performance needed significant improvement to reduce risks to people who used the service. Managers monitored the numbers of incidents at Peninsula Hub quarterly to identify any themes and trends and acted where necessary. However, they were not always reported to all relevant external bodies, in line with legal responsibilities. Additionally, incident investigations were not comprehensive and did not give assurance of actions taken. We saw an incident report raised by the local NHS trust where a scan had been misdiagnosed. We reviewed the service’s investigation which gave no assurance or evidence any of the identified actions had been taken.

Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses. However, not all relevant staff, services, and people who used services were always involved in these reviews and investigations. We saw 1 incident where a patient had been turned away from having a scan due to a breakdown in communication between the service and the local integrated care board. This meant the patient did not receive their scan and later presented to the local emergency department. We also saw another incident where an employee was injured which was reported to the Health and Safety Executive (HSE) as required under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR), outside of the required time frames.

Leaders and staff did not always strive for continuous learning, improvement and innovation. The provider did not hold any external quality accreditation, and we did not see any evidence of regular quality assurance carried out on ultrasound machines. Staff explained some machines provided clearer images than others, which the local NHS trust had also fed back to the service. Following our inspection the service had developed a quality assurance programme for all machines and had begun implementing a cloud based HR system to fill in missing gaps identified in paper records.

Teams sometimes worked together to identify and share learning. We reviewed one incident investigation where a patient had been turned away from having a scan due to a breakdown in communication between the service and the local integrated care board. The service, in collaboration with external partners, implemented actions and a standard operating procedure which included clear communication escalation pathways.

Some staff worked together to resolve problems, but this did not always lead to improvements and better working relationships.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Quality Statement Score: Your judgement of the quality and safety of the topic area

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service did not always carry out comprehensive risk assessments for people who used services and staff did not always identify and respond appropriately to changing risks to people. Staff and managers explained they often received patients from care homes or who used transport services, who were not suitable to be scanned at the remote location. There were no clear exclusion criteria which would guide referrers on which patients could safely access the service. For example, staff told us a patient brought in on transport attended, who then had to wait to be picked up from the clinic. The service had no reception desk or clinical staff to maintain oversight of this patient or to follow up on their transport, meaning the service could not assure the patient was safe or had a suitable area to wait to be collected. Following our inspection the service developed a clear policy for patients who were suitable to access the service.

There were procedures for the management of a collapsed patient, and staff were clear on what to do in the event of an emergency.

Some clinical staff had received training in basic life support (BLS). Data submitted showed 25 out of 36 staff (70%) had undertaken this training. This meant some staff may not know how to respond in the event of an emergency.

Staff followed processes to ensure the right person got the right radiological scan at the right time. Identification checks were carried out and recorded for all patients before they had their scans.

The service followed the Royal College of Radiologists standards for the communication of radiological reports and fail-safe alert notifications including the communication of significant or unexpected findings.

The service did not have access to a medical physics expert, so it was not clear who they contacted in the event of any anomalies or physics related issues in regard of the ultrasound machines.

Images and reports were available to cancer multi-disciplinary teams in a timely way, however, the service had received feedback from the local NHS trust about the quality of some of the transvaginal scan images. This had resulted in 1 machine no longer being used for that type of scan.

Staff followed protocols to check and ensure requests for imaging procedures met the needs of the patient. Where there were multiple IT systems, the service ensured information was shared and accessed securely when required. However, for the post-menopausal bleeding clinics, staff only received a list of patient names rather than formal ultrasound requests. This meant staff would not have access to any additional information about the patient such as medical alerts.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Quality Statement Score: Your judgement of the quality and safety of the topic area

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

The service shared safeguarding concerns quickly. However, not all staff had received safeguarding training at the correct level for their role. For example, the safeguarding lead for the provider was only trained to level 3 which is not in line with the Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff. Additionally, we saw another manager named as deputy safeguarding lead who, according to the data submitted, had only completed level 1 adults and children safeguarding training. Following our inspection, evidence was submitted to show they had now undertaken level 3 training.

Staff we spoke to could identify when to report abuse and how and made appropriate referrals to external agencies. Staff were not trained to the correct level for their roles but did understand the relevant requirements of legislation and guidance. However, only 73% of staff had undertaken level 1 adult safeguarding training and 60.5% had undertaken level 1 children safeguarding.

Information regarding safeguarding from abuse, sexual safety and domestic abuse was displayed where service users could see it. The service also had a chaperoning policy for all patients that staff were aware of and understood.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Quality Statement Score: Your judgement of the quality and safety of the topic area

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Referral criteria were not effectively communicated to referrers as patients were continuing to attend in both wheelchairs and on hospital transport and the service had no formal policy to explain which patients they could and could not scan. At the time of our inspection a patient attended on a home oxygen cylinder which was almost empty. The clinic was not equipped with any piped oxygen or oxygen cylinders. Staff were unaware of this patients’ needs before they attended. Since our inspection, the service had implemented referral criteria policy for referrers.

The service identified and met the information and communication needs of people with a disability or sensory loss. Leaders ensured services were delivered and made accessible to take account of the needs of different people, including those with protected characteristics under the Equality Act. However, due to the physical layout of the clinic, patients had to be able to freely transfer onto the ultrasound beds.

Staff enabled patients to give feedback on the service they received. Patients we spoke with said they felt supported by staff. We saw evidence that patient choice was respected when deciding which scan clinic to choose.

The clinic did not have access to medical support in the event of an emergency as it was in a remote rural location. If there was a patient whose health was deteriorating staff called 999 to request an emergency ambulance to take the patient to accident and emergency department. Staff were trained to carry out basic life support, in line with Resuscitation Council UK Guidelines 2025, until further help arrived.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Quality Statement Score: Your judgement of the quality and safety of the topic area

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The design, maintenance and use of facilities and premises generally kept people safe. Clinical rooms had clear signs to restrict access. However, there was no reception desk, and patients used a tablet to self-check in. Some patients told us this was confusing.

Equipment was maintained and serviced in line with manufacturer guidance or whenever issues arose. However, there was no programme of regular quality assurance as recommended by the British Medical Ultrasound Society. This meant the service could not be assured that equipment was suitable for purpose, regularly inspected, properly maintained and that risks were assessed and mitigated. There was a maintenance contract, but this did not include quality assurance. Following our inspection the service developed a quality assurance schedule.

The service held an asset register which showed the age of equipment and helped senior staff and managers plan any capital replacement projects.

Arrangements for managing waste did not always keep people safe. The service used yellow and black tiger bags for disposal of all waste, including bloodstained non-infectious items. However, we saw this was being disposed of alongside other domestic waste which was not line with NHS England Health Technical Memorandum 07-01: Safe and sustainable management of healthcare waste, which recommended this type of waste should be incinerated. Data submitted showed the service had revised its policy following our inspection, to ensure waste disposal was in line with legal requirements.

Electrical equipment was not tested for electrical safety. We saw 8 plugs in 2 ultrasound rooms and 2 plugs in the waiting area with safety test review dates of March 2025. Data submitted stated the service undertook testing every two years, however this did not align with visual stickers on devices.

IT systems helped managers monitor demand and capacity of the service for future planning. For example, a new, easier requesting system had been introduced to GPs which had seen a spike in ultrasound referrals into the service.

The service was aware of its responsibilities to undertake assessments and reviews of their activities under the Control of Substances Hazardous to Health Regulations 2002 (COSHH). At the time of our inspection, there were no items on the premises subject to COSHH.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

Quality Statement Score: Your judgement of the quality and safety of the topic area

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service did not ensure staff were up to date with all the mandatory training they needed to carry out their roles. For example, data submitted showed 63% of healthcare assistants were up to date and 72% of sonographers. Most dates on the training records had also been updated after our assessment. In addition, 5 sonographers had undertaken mandatory training through other NHS employment, but there were no dates or evidence to support this recorded.

A number of staff were not up to date with essential resuscitation training. Not all staff received effective training in safety systems, processes and practices. Data submitted showed 73% of staff had undertaken basic life support training in line with company policy.

Not all staff had regular appraisals or a 1-to-1 conversations. Data submitted showed 3 staff had received clinical supervision, which had all taken place following our inspection. Additionally, data submitted showed 6 out of 43 staff had received an appraisal, however the service had a schedule to implement the rest of the appraisals over the coming year.

Staffing levels and skill mix were planned and reviewed so that people always received safe care and treatment, and staff did not work excessive hours. Actual staffing levels and skill mix compared well with the planned levels and cover was provided for staff absence.

There were enough radiologists and radiographers/sonographers to meet the demands of the service. Radiologists were available to provide advice each day. Radiographers/sonographers who worked at the service had received inductions and training which were up to date.

The service ensured relevant staff continued their registration with relevant bodies and gave support with revalidation where necessary.

Staff who were undergoing training, such as student sonographers, were adequately supervised. Staff who had trained outside of the UK were subject to a period of enhanced support and double reporting from senior sonographers in the service.

Time for staff to plan and obtain any additional information required to perform safe scans, such as blood test results, was factored in to lists. However, there was no regular programme of daily or weekly checks for the ultrasound equipment.

Engineering support was supplied by formal maintenance contracts with external partners. Staff told us they responded promptly in the event of equipment failure.

Staff did not always receive training to make them aware of the potential needs of people with mental health, living with a learning disability, autism or dementia needs. Training records showed training compliance was 43%. We saw no plans to improve this.

Staff were trained up by the service and supported to undertake their university qualifications to become sonographers. They were supervised by senior sonographers in the service to achieve sign off for standalone scan reporting.

The service supported professional development and career support through specialist training including musculoskeletal, (MSK) study days, paid development time, mentorship, and clinical governance learning.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Quality Statement Score: Your judgement of the quality and safety of the topic area

1. We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service did not maintain high standards of cleanliness and hygiene. The service did not have reliable systems to prevent and protect people from a healthcare-associated infection. For example, the service was not effectively cleaning transvaginal (TV) ultrasound probes. TV probes are classed as semi critical devices and require high level disinfecting between patients. The service was not following British Medical Ultrasound Society (BMUS) best practice guidance which stated TV probes required initial cleaning with either soap and water or a surface wipe followed by a high-level disinfectant cleaning system. Staff explained they only used surface wipes in between patients, and the infection prevention control policy did not provide any details of guidance for staff. We raised this with managers who voluntarily suspended TV scans whilst they sourced an alternative cleaning system. Following our inspection, managers confirmed they had restarted scanning using a high-level disinfectant system to clean TV probes in between patients. This was corroborated by an updated policy and updated mandatory training for staff.

The service did not record probe serial numbers used in TV scanning. TV probes are inserted into the vagina to give a different view of pelvic organs and can carry enhanced risk of infection. This meant that in the event of a cross-infection issue, the service would not be able to trace which probe had been used on which patient.

The service did not audit environmental cleanliness or hand hygiene. During our inspection we did not see any records of any cleaning of the clinical rooms. We requested data which showed since our inspection the service had implemented a hand hygiene and environmental checklist. However, this identified there were still areas of non-compliance for example, transvaginal probe decontamination was not done in 8% of cases on 1 day of checks.

Staff were provided with clean uniforms and were familiar with the uniform policy around covering their uniform when travelling to and from work. However, we saw staff wore excessive jewelry and some had false nails and nail varnish, which was not in line with infection prevention and control best practice guidance or provider policy.

Staff took precautions when seeing people with suspected communicable diseases and had access to personal protective equipment such as gloves and masks. However, only 75.5% of staff had undertaken infection, prevention and control mandatory training.

Staff and carers used personal protective equipment when needed including aprons, masks and gloves.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Quality Statement Score: Your judgement of the quality and safety of the topic are

3. We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service did not keep, use or store any medicines at its peninsula hub clinic.