Phoenix Ultrasound

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

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 leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, and person-centred, and to reduce inequalities.

This is the first assessment for this service. This key question has been rated good. We identified breaches in the legal regulations relating to governance.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The company had a shared vision, strategy and culture.

The service had a vision and mission statement, underlined by values and a strategy. It was evident staff worked closely together to achieve the company goals. The plan was to expand the business and open a branch in London. At the time of the inspection there was no growth strategy in place to support this.

Not all leaders understood the context in which the service delivered care, treatment and support. They did embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The service was made up of a lead sonographer, who was also the chief executive of the company, a second sonographer, 2 administrative staff, and one Registered Manager. The Registered Manager started at the company in December 2024 and had since ensured systems and processes were in place and updated as required. The Registered Manager was knowledgeable and honest. They agreed governance required strengthening and embedding. The Registered Manager only attended the clinic in person approximately once a month.

Although the lead sonographer and administrator were engaged and clearly proud in the company, it was evident there was a lack of understanding of areas relating to governance and regulation.

The organisational structure showed who reported to who. It was not clear who the lead sonographer reported to and how the service ensured their competencies were regularly reviewed.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had an up-to-date Freedom to Speak Up policy, outlining when and how staff should or could speak up. There were internal and external ways for staff to speak out. The policy clearly showed an understanding of the potential difficulties of speaking up in a small company and contained signposting information for further support.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The company had an up-to-date Equality, Diversity and Human Rights policy outlining the service’s commitment to promoting a culture of equality and diversity to all individuals, including amongst staff. All staff received training in equality and diversity.

On the day of the inspection, we observed communication and behaviour between the lead sonographer and one of the administrators. It was evident they respected each other as people and professionals.

We observed interactions with staff and patients from a variety of cultural backgrounds and felt everybody was treated as individuals.

The service had clear responsibilities, roles, and work was ongoing to improve their governance. Staff did not always act on the best information about risk, performance and outcomes.

In December 2024 the company had employed a new Registered Manager who was responsible for strengthening the service’s governance and work was continuing. We observed some practices which were not in line with current guidance, and which had not been identified through the providers own monitoring.

The provider’s website inferred staff were doctors, midwives, and phlebotomists. Whilst they may have had this role by background, this was not in reality what they did at this clinic.

The service had a business continuity and disaster policy in place, which covered potential disruptions, such as staffing crisis, pandemic illnesses, climate events, etc. The Registered Manager acted as the business continuity plan coordinator.

The service had a data protection officer who was responsible for ensuring full compliance with all information governance related legislation. Patient records were mostly electronic.

The service did not keep a written record of any of the staff members’ competencies. The SOR and BMUS state all ultrasound practitioners must have documented evidence of their competencies.

The service conducted monthly team meetings and monthly clinical governance meeting, with minutes recorded for both. A risk register was in place, outlining impact and probability of risk and up-to-date action plans to remedy any risks. Risk was a standing agenda item for the service’s monthly clinical governance meetings.

Although the company vision outlined continuous service improvement through audits, we did not see evidence of clinical audits being conducted.

Staff shared information with other professionals with the consent of their patients. They did not routinely share information when patients did not give consent. Whilst independent practices may not be obligated to do this, we expect the systems and pathways, when unexpected findings are discovered, to be robust.

The service focused on continuous innovation and improvement across the organisation.

The service was committed to continuous improvement by adopting advanced technologies to provide high standards of care. Staff told us the company actively invested in innovative ultrasound technologies to enhance diagnostic accuracy. For example, the service had invested in an ultrasound machine capable of performing shear wave elastography. This is a technique to measure tissue stiffness.