Peninsula Hub Also known as Peninsula Ultrasound Limited

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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We have not awarded this service a score for Well-led.

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

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service had a vision and strategy for achieving the priorities and delivering good quality sustainable care. Some staff were aware of this. Through relationships and partnerships with other stakeholders, the provider had secured additional contracts and had expanded to other regions. However, contract meetings were KPI and report quality focused rather than viewing the service holistically. This meant there were lots of variance in practice across different contracts. For example, in the community hospitals, staff followed different probe cleaning guidance to the peninsula hub location.

Some staff felt supported, respected and valued which was reflected in the 2025 staff survey results. Some staff felt positive and proud to work in the organisation, but several staff were actively looking to leave the service, and some were fearful of reprisals if they were to leave the service.

The culture was centred on the needs and experience of people who used services. However, staff reported having their professional and clinical judgment was questioned by non-clinical managers.

There was not a strong emphasis on the safety and well-being of staff, who reported working in isolation at times which had affected their mental health.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

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 inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders did not demonstrate they all had the skills, knowledge, and experience that they needed to manage this service. They did not always identify risks to patient safety and did not identify the actions needed to address them. For example, ensuring all equipment was cleaned and quality assured in line with manufacturer and best practice guidance, especially in relation to infection, prevention and control.

Leaders understood challenges for the service and were active, but staff told us they were rarely visible to them. At the time of our inspection there were no senior clinical staff on site however staff explained they were contactable by phone and generally responsive to requests, although remote.

The management structure ensured there was senior support and specialist advice for staff when the needed it, but staff were not always clear on when to ask for additional support.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

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. People did not feel they could speak up and that their voice would be heard.

Staff felt able to speak up but were fearful of retribution or unfair treatment if they did.

At the time of our inspection, the service did not have a freedom to speak up guardian. Since our inspection the service has developed a freedom to speak up policy.

The service had a whistle blowing policy which set out the steps staff could take to raise a concern and what response to expect from the service.

Some staff were confident in raising concerns with line managers but did not always feel supported by them.

Staff contributed to staff surveys and but did not always feel action was taken as a result. For example, staff reported concerns around infection control policies, which they told us, were ignored.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

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 value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There was not a strong emphasis on the safety and well-being of staff, who reported working in isolation at times which had affected their mental health.

Staff did not work as 1 big team and responsibility for providing good, safe care and resolving issues together was not prompted. Staff worked in clinics on their own with a healthcare assistant and did not always know who other sonographers were or collaborate with them. However, an online directory of all staff, including their role, was available.

Staff were actively engaged so their views were reflected in the planning and delivery of services and in shaping the culture. For example, the ultrasound management team regularly met and held good quality discussions about the day to day running of services and plans for the future.

Most staff felt supported, respected and valued which was reflected in the 2025 staff survey results. Some staff felt positive and proud to work in the organisation, but several staff were actively looking to leave the service.

Staff were able to request reasonable adjustments and changes to working arrangements which were considered by managers.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

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 clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not have effective, clear structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services. Governance structures did not function effectively and there was little oversight of incident investigations or evidence of actions. Additionally, we reviewed 6 staff records and saw significant gaps in mandatory pre-employment and ongoing employment checks including missing identification for 3 members of staff, missing or incomplete references for 4 members of staff, right to work evidence missing for 6 members of staff, no CVs for 6 members of staff and no interview notes for any staff files we reviewed. This meant the service could not be assured of the workforce suitability, right to work compliance, or accurate employment and identification records. Additionally, no staff had received an appraisal since 2024.

The service had a limited programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken. Where audits had been completed, we saw they were reviewed at the relevant committee meetings and reported to the overarching governance committees where we saw discussion around report accuracy and improvement. However, at the time of inspection, there was no quality assurance of equipment and inadequate infection prevention control measure and traceability of transvaginal probes. Following our inspection, the service implemented a new transvaginal probe traceability protocol requiring serial numbers of probes to be recorded against each patient.

However, staff at all levels were generally clear about their roles and they understood what they were accountable for, and to whom. Organisational structure charts were clear and accessible to staff.

The provider did not ensure that all staff underwent appropriate checks as required by Schedule 3 of the HSCA 2008 (Regulated Activities) Regulations 2014. This is a requirement for all staff which should be carried out before staff begin their employment with a service.

Safety was not always promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks. We reviewed 6 personnel files and saw evidence of appropriate Disclosure and Barring Service (DBS) checks relevant to the role of the staff member but missing identification in 3 cases and no right to work recorded in all 6 cases.

Arrangements with partners and third-party providers were governed and managed effectively to encourage appropriate interaction and promoted coordinated, person-centred care. There was a comprehensive structure tor reviewing contracts.

There were a range of meetings with specialist responsibilities. For example, there was clinical governance meeting and managers meeting. These meetings covered, changes to practice, new guidance, complaints and reported incidents and actions.

Risk registers were clear and up to date and there was alignment between the recorded risks and what staff said was ‘on their worry list’.

Potential risks were considered when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities. Senior managers gave us examples for where they had been asked to extend their services to support the post-menopausal bleeding service and how they had flexed to meet this demand.

The service implemented external alerts such as MHRA or patient safety alerts through management meetings which were minuted and disseminated to those who were unable to attend. Where serious enough, staff kept written records to confirm which staff had seen the alert or update.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

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 understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, but did not consistently report them internally and externally. All staff knew how to report incidents using the provider’s electronic system. However, we saw an incident where a member of staff had sustained a serious injury at work which had not been reported within required time frames to the Health and Safety Executive (HSE) as required under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

The service reviewed and investigated safety and safeguarding incidents and events when things went wrong. However, not all relevant staff, services, partner organisations and people who used services were involved in these reviews and investigations.

Learning from lessons was shared to make sure action was taken to improve safety. For example, a patient had attended for a scan, and the service did not have the patient details or request, so the patient was not scanned and later passed away. The incident investigation showed the root cause was a failure in communication between the integrated care board (ICB) and the service. As a result, the service, along with local partners, had developed a standard operating procedure which included a clear escalation process to follow if a scan was unable to go ahead either through lack of capacity or missing information.

There were positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant population, and to deliver services to meet those needs. The service was integrated with the local ICB and had secured funding to take over bookings in-house which would ensure accuracy of requests and remove any duplication. There were regular contract meetings around key performance indicators such as report turnaround quality.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

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 focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders and staff did not always strive for continuous learning, improvement and innovation. Investigations into incidents and complaints were not comprehensive and lacked detail and evidence of improvement, even when requested by external partners.

The service did not hold and had no plans to go for UKAS accreditation or any other external validation or accreditation schemes.

Staff meetings took place in both Cornwall and Devon to ensure staff attendance. Staff were able to discuss training courses and other issues to aid in the development and improvement of the service.

Senior staff and managers were able to allocate time to work together to resolve problems and to review individual and team objectives, processes and performance. Although there was limited evidence this had taken place prior to or assessment.

Staff meetings had led to some improvements in patient care and better working relationships within the service and with partner agencies. For example, regular manager meetings showed discussion around audit results plus action plans.