Phoenix Ultrasound

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• 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. This was the first inspection for this service. This key question has been rated requires improvement.

We identified 4 breaches of the legal regulations. This meant leaders did not always know how to ensure people were safe from harm. The service did not always make sure there was continuity of care. Staff did not consistently carry out identity checks of patients. Staff were not consistent in their approach to handwashing prior to examinations.

This service scored 50 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service used an online provider for their mandatory training and kept a training log. All staff were up to date with their mandatory training relevant to their role. The provider logged near misses and incidents on an internal incident log. Incidents were discussed at the monthly clinical governance meeting. The provider had an up-to-date Freedom to Speak Up policy.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. Staff did not always manage or monitor people's safety. They did not always make sure there was continuity of care.

The service did not have local mechanisms to alert other professionals when they identified significant and unexpected findings during an ultrasound scan. There was no clear local protocol in place to manage unexpected or significant findings, which BMUS expects as best practice. We witnessed the sonographer advised patients verbally to seek GP or other medical support, and written information about other services was available in the waiting area. The reports we received contained a standard phrase advising patients to share reports with their GP or specialist.

Sonographers do not diagnose medical conditions themselves but are able to comment on suspected diagnoses. Their role is to capture high-quality images, which are then analysed by physicians. We saw the sonographer clearly stated suspected diagnoses, which was in line with the guidelines.

Most patients self-referred and the provider did not routinely record their GP details. These were only obtained if a patient agreed to the ultrasound scan report being shared with their GP.

The Royal College of Radiologists' (RCR) guidelines outline diagnostic scanning services should have protocols in place, containing information about referral pathways should an unexpected finding be found during a scan. The service did not have this in place.

The service did not always understand what being safe meant to patients and how to achieve that. They did not know how to share safeguarding concerns quickly and appropriately.

We were not assured staff knew what to do when they were concerned about an individual's safety. When we asked them about various scenarios, such as female genital mutilation (FGM) or concerns of adult or child abuse, they were unable to describe what they would do. The Registered Manager was informed and was clear about the action they would be required to take. They were aware this was an area which required improvement, and they had started to discuss scenarios at their monthly team meetings, with the aim of improving staff’s understanding. This was reflected in the minutes of the monthly meetings we reviewed.

The service had up-to-date adult and children safeguarding policies and a safeguarding lead. The policies outlined types of abuse and staff responsibilities for reporting concerns. Clinical staff received level 2 children and level 3 adult safeguarding training; administrative staff received level 2 children and adult safeguarding training. This was in line with the intercollegiate guidelines of safeguarding.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, the service did not always work with people to understand and manage risks.

Staff did not always explain procedures fully before commencing the scan but offered patients the opportunity to ask questions after the procedure.

Staff did not always undertake required checks to confirm patients’ identity. This meant there was no consistent process for staff to confirm they were scanning the correct person. We observed the sonographer show patients the ultrasound screen to confirm their name and date of birth. On one occasion the incorrect patient had been put up on the screen; however, the sonographer noticed this error and changed the screen. On another occasion we observed the sonographer did not check a patient’s details at any point. The Royal College of Radiologists outline established good practice requires the patient to give their name, address and date of birth.

Staff did not have access to patients’ medical records. They solely relied on patients sharing their own medical information and history,which BMUS deems acceptable. Patients completed a pre-scan questionnaire and answered relevant clinical questions during the scanning appointment.

All staff received training in basic life support. One of the administrators was the first aid lead. Fully stocked and in date first aid kits were available in the clinic area. Staff knew how to access the automated defibrillator kept on the ground floor and knew what to do in an emergency, if a patient suddenly deteriorated.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The service had 2 ultrasound machines, and both included transvaginal (TVS) probes for internal examinations. The sonographer appropriately cleaned the probe after every scan. Staff kept an audit record of TVS procedures and probe decontamination. They did not record the serial number of the TVS probe, which would be best practice. If an ultrasound machine was to break down, staff knew to contact the company who provided the machines. They told us this had not happened yet, and they had access to a back-up machine.

Ultrasound machines were checked annually by the maintenance contracted provider. as well as this, the service carried out regular daily and weekly checks, which was in line with the guidelines from the Medicines and Healthcare products Regulatory Agency (MHRA).

The service had enough qualified, skilled and experienced staff. They worked together well to provide safe care that met people’s individual needs. However, the service did not always make sure staff received effective support, supervision and development.

The service had an up-to-date supervision policy in place. However, staff did not currently receive supervision as outlined in the policy. Staff told us this was due to the service being small and monthly meetings currently served as supervision. We did not see supervision notes in any of the meeting minutes reviewed. Out of 5 staff members, 4 started less than 1 year ago and appraisals had not yet begun. The service had a recruitment policy outlining processes for the safe recruitment of staff. All staff had Disclosure and Barring Service (DBS) checks in place. Competencies were assessed by reviewing relevant qualifications, for example: a curriculum vitae (CV), training records, or references. We reviewed one staff member’s recruitment file which contained appropriate checks and records. However, the service did not have written records of competency review and checks for sonographers.

The service employed 2 sonographers, 2 administrative staff, and one Registered Manager. They had access to a pool of self-employed sonographers who they could call on if they needed extra help. There was always a minimum of 2 staff members on site

All new members of staff underwent a full induction pertinent to their role. For clinical staff this included a full induction with the ultrasound machines. The lead sonographer reviewed all other sonographers’ reports for the first month of their employment.

The service did not always assess or manage the risk of infection.

The service rented 2 rooms from a GP surgery. As part of this contract the GP surgery was responsible for cleaning and waste management. We saw the cleaning log, which was not always completed consistently. Phoenix Ultrasound staff told us they were not satisfied with the level of cleanliness provided by the GP surgery, and they carried out their own cleaning. However, this was not recorded. The Registered Manager was currently in talks with the GP surgery to improve the service provided.

We observed staff were not consistent in their approach to washing their hands prior to patient contact and when they wore gloves. For example, the sonographer washed their hands whilst talking with the patient prior to the scan but then left the room touching the door handle. They did not re-wash their hands when they returned to carry out the scan. Gloves were consistently worn when undertaking transvaginal scans; however, for other scans the donning of gloves was inconsistent. The service undertook regular monthly hand hygiene audits, and the results indicated 100% compliance.

The service had pre-filled ultrasound gel bottles, which were in date. We saw the sonographer appropriately disinfected the TVS probe prior to its use. The service kept a log of daily probe cleaning checks, and this log was up to date.