Ultrasound Direct Southwest Coast

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first rating for this key question. This key question has been rated good.

We have not awarded this service a score for Effective.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

The service carried out risk assessments through the initial online pre-booking questionnaire to determine the person’s eligibility. However, the services processes did not always consistently identify or consider additional needs of people using the service. These included language, cultural, religious and accessibility requirements for people and their relatives. This meant the service did not always make reasonable adjustments in advance, in line with Equality Act 2010, to promote dignity, equality and inclusion.

Managers and staff told us they did not routinely contact people before appointments to gather further information about individual needs such as mental health status or communication requirements. Staff gave examples of people whose needs were only identified on arrival or at time of the scan. This included a patient who did not speak English as a first language, attended with a family member. Staff were unaware of these needs until the patients arrived at the clinic limiting the opportunity to plan support in advance.

While staff responded effectively once these needs became known, the lack of a proactive process increased the risk that people’s individual needs were not fully addressed prior to attendance. This meant it may limit the clinic's ability to ensure arrangements consistently support dignity and patient centred care.

Staff would assist patients into comfortable positions for imaging wherever possible. People had access to drinking water as needed or required. There was a water dispenser for patient use.

We reviewed 10 patient care records which included the preadmission terms, the conditions assessment and the scanning reports. The preadmission assessment included details of any allergies, condition, previous pregnancy information (including number of miscarriages), along with details of the service planned and cost. All assessments were signed and dated by the patient attending. Scan reports included pregnancy dates, details of sonographer and chaperone, confirmed consent and then the details of the scan. Where anomalies were identified, there was clear written and verbal advice on what the patient should do.

We scored the service as 2. The evidence showed some shortfalls. The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The service did not consistently demonstrate that care and treatment were delivered in line with current evidence-based practice and governance arrangements did not provide sufficient assurance that clinical standards were being maintained and monitored.

The service could not demonstrate that staff were accessing current and up to date policies and procedures to guide their practice. Each clinics policies and procedures were stored on an online single accessible through a single laptop and in one physical paper folder. However, we saw that most of the documents in the folder, did not align with the versions available online. The online system included standard operating procedures (SOP), which were not present in the folder. Leaders told us that they used both the folder and the online system. This meant staff could not be certain that the documents they were referring to represent the most recent versions. Also, several policies reviewed during the assessment were overdue for review. This all meant that there was a risk that clinical practice was being guided by outdated or superseded policy without staff or leaders being aware of this.

There was no structured process to ensure ongoing clinical competency beyond the initial induction period. While new clinical staff received induction period of supervision, and the service carried out monthly image, report and rescan audits with feedback given to sonographers, there was no routine peer review or supervision process to ensure continued competency once induction was completed. There was no process to review or audit new aspects of clinical practice.

Staff told us they followed professional guidance and described working in accordance with national standards and established pathways. Sonographers explained referral processes for suspected ectopic pregnancy, abnormal findings and urgent escalation to NHS services.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff worked collaboratively as a team to provide safe and effective care for patients. They supported each other to deliver a high-quality service, ensuring punctual shift starts and carefully planning patient care. We observed them supporting each other and building a good rapport with the patients and their relatives. Staff across all sites supported one another by covering shifts using an online application for staffing arrangements. People using the service felt the team worked well together.

Staff worked effectively with colleagues and external services to support people receiving care. Sonographers described clear escalation arrangements for unexpected findings and referral pathway into NHS services. Staff explained how they shared information with healthcare professionals when further investigations or specialist review were required. Staff identified managers and clinical leads who could provide advice when concerns arose.

However, the service did not supply evidence of handover audits or policies governing external handovers and care record transfers. This meant that the service had limited assurance regarding how information sharing arrangements were monitored and evaluated.

Although staff worked well together, evidence showed that staff did not have the same relationship with senior leaders.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support. However, there was limited evidence provided demonstrating a structured health promotion programme or evaluation of health promotion activity across the service.

Staff supported people to understand their health needs and make informed decisions about their care. Staff explained scan findings within the limits of their role and provided information about procedures, follow up arrangements and referral pathways, where required. People were given information about scans, consent processes and next steps in their care. Staff described discussing concerns sensitively and directing people towards other healthcare services where further assessment was required.

Leaflets promoting mental health and addressing anxiety were readily available. Posters offering domestic abuse support were discreetly displayed on toilet doors.

Staff demonstrated an understanding of the importance of reviewing not only the progress of pregnancies but also identifying and referring any potential gynaecological concerns.

The service had a website which contained educational articles covering a range of conditions relevant to the scans such as kidney and bladder health, endometriosis and the role of ultrasound in detecting abnormalities. Endometriosis is a condition where tissue similar to the lining of the womb (uterus) grows outside the womb, such as on the ovaries, fallopian tubes, or other areas in the pelvis.

However, the website did not contain broader health promotion content. There was no lifestyle advice, no signposting to national health campaigns or public health resources, and no links to external support services beyond the services own scan and blood test offerings. The service had not used its digital platform to actively promote the wider health and wellbeing of the population it serves.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service carried out a range of audits, including transvaginal consenting, decontamination, hand washing and general clinic compliance checklist. This showed that the service had identified areas of practice that needed to be monitored and had put tools available to do so.

However, we could not determine which key performance indicators were routinely monitored or how performance data was analysed and translates into action. This meant that while data was being collected, there was insufficient evidence that it was being used effectively to identify trends, address shortfalls or improve outcomes for people using the service.

An in-date data retention policy was reviewed; however no specific data retention period was stated within the policy. This meant the policy did not provide staff with clear guidance on how long different categories of data should be retained.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff supported people to make informed decisions about their care and treatment. Staff we spoke to, demonstrated a good understanding of consent processes and described obtaining consent before scans were undertaken.

We saw staff explained procedures, risks and limitations before treatment and gave people opportunities to ask questions. Staff described assessing, understanding and adapting communication where required.

The service transvaginal consent audit showed 100% in January 2026 and February 2026.

However, the provider did not provide clarity regarding Mental Capacity Act training compliance. Training records showed only 3 staff out of the active 50 staff members had completed this training, but it wasn’t clear who exactly had from the evidence provided. This meant that the service could not assure itself that all staff had received training to support people who may lack capacity.