Ultrasound Direct Southwest Coast

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

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety.

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.

We scored the service as 2. The evidence showed some shortfalls. The service reported safety events; however, these were not always investigated comprehensively or followed through with appropriate outcomes. Lessons were not always taught to continually identify and embed good practice.

The service did not demonstrate a culture of learning and improvement following incidents. In the past year the service had reported 3 incidents. A review of the incident log identified that following a serious injury to a person under their care, there were no documented lessons shared with the wider team, and the “lessons learned” field was recorded as “no”. There was no evidence of a post-incident review or environmental audit. The root cause was attributed solely to the injured persons responsibility without corroborating investigation or documented clinical rationale. Duty of candour considerations were not recorded as having been explored, despite the person sustaining a physical injury. While staff responded effectively in the immediate aftermath and completed both an accident and clinical governance form, the provider did not demonstrate that incident data was investigated comprehensively or followed through with appropriate outcomes.

The other 2 incidents highlighted that key fields, such as "signed off by" and "date incident closed", had not been completed. This was particularly significant for one incident involving equipment failure, where the immediate action taken indicated that the issue had been resolved, yet the incident had not been formally closed or signed off.

The service did not have an in-date duty of candour policy. However, staff demonstrated a clear understanding of the duty of candour, showing openness and honesty when things went wrong.

Several policies and procedures we reviewed were not in date. However, they did align with national guidance. This included standards from the Royal College and Society of Radiographers, the foetal abnormality screening programme, and the British Medical Ultrasound Society

There had been no reported never events in the last year. Never events are serious, largely preventable safety incidents which should not occur if the available preventative measures are followed.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The service offered a wide range of diagnostic and screening services. Their services include pregnancy scans, gender scans, general health and musculoskeletal scans, fertility assessments, and diagnostic blood tests.

The service’s electronic booking system was monitored daily, offering people the flexibility to book appointments online via a 24/7 platform or by contacting the clinics directly with customer service support available. The service was open 5 days a week including some evenings and weekends. The booking system issued automatic appointment reminders and allowed short notice rebooking. We saw evidence that managers followed up with people who did not attend appointments.

People completed a pre-scan questionnaire on arrival to the clinic, which included pregnancy history and a signed declaration confirming NHS care and consent to share medical information if required. There were clear referral pathways with local NHS providers if foetal abnormalities were suspected. When required, staff contacted the relevant NHS units directly and arranged appointments on the persons behalf.

The service had an established referral pathway that supported the safe and timely escalation for concerning findings detected during the ultrasound examinations. The service held documented clinical decisions pathways for a range of gynaecological presentations, including postmenopausal bleeding, detected endometrial thickening, simple and complex ovarian cysts in both pre- and post-menopausal people and findings suspicious of malignancy.

These pathways were supported by defined clinical thresholds to guide escalation, including urgent two-week-wait gynaecology referrals when features suggestive of malignancy were present. This provided staff with a structured, clinically supported framework for making onward referrals, helping to minimise delays in identifying serious pathology.

The service demonstrated awareness of the importance of continuity and geographical accessibility in its referral arrangements. Pathways were tailored to the hospital trusts within the geographical catchment of each clinic, with the service holding separate referral documentation for each local hospital. This meant people were not disadvantaged by their location and could be referred to a secondary care setting accessible to them.

We observed sonographers checking people’s understanding of their referral prior to scanning and explaining when reports would be sent to the referrers.

However, the service could not fully demonstrate the referral pathways were consistently embedded in practice or subject to regular governance oversight. While documented pathways existed, there was no evidence reviewed during the assessment that these were subject to audit, that staff competency in applying them had been assessed or that outcomes following the referral were tracked or reviewed. This meant the service could not assure itself that the existence of the referral frameworks were being applied correctly and consistently across its clinical workforce, or people were achieving safe outcomes as a result of the pathways available.

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.

The service could not demonstrate that people were protected from abuse and improper treatment, and there were no effective safeguarding frameworks to support staff to recognise or respond to concerns. Both the safeguarding adults and safeguarding children’s policies were out of date and overdue for review. This meant the framework staff were expected to work within did not reflect current guidance or legislation. This also meant staff had no reliable policy foundation to guide their practice.

Staff across the service did not have the training required to recognise and respond to safeguarding concerns. The service reported employing a total of 50 active staff members. However, the evidence provided only included training records for 25 staff. Of these 25 staff members, three had not completed Level 1 and Level 2 safeguarding training for adults and children. Managers advised that these staff members were still in the process of completing the required training at the time of the assessment. No safeguarding training records were available for the remaining 25 staff members. This meant that the service could not assure itself that its workforce had the knowledge or skills to identify abuse, respond or make timely referrals to protect people from harm.

The registered manager and the regional manager had completed safeguarding level 3 and level 4 respectively. The registered manager is the safeguarding lead, and this was a required standard in line with the Intercollegiate document (2025) Safeguarding children and young people & children and young people in care: Competencies for health care staff.

Staff could identify safeguarding leads and understood escalation routes. Staff described seeking advice from managers when concerns arose and knew who to contact within the organisation. Staff we spoke to could identify when to report abuse and how and made referrals to external agencies. The service had a safeguarding referral pathway and had made safeguarding referrals to the local authority safeguarding teams. However, the service did not provide evidence of the outcomes of referrals made or learning identified from safeguarding cases.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were informed of options and risks and were signposted to support as necessary. Records reflected any foreseeable risks and steps to be taken to address these. Sonographers were experienced staff who were able to determine risks associated with the scans and therefore signposted to other services or clinicians.

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.

Staff had access to a first aid box and items within were in date. We saw evidence of up-to-date risk assessments for fire safety and health and safety to identify and mitigate environmental risks. These clearly identified risks, control measures and named staff responsible for monitoring.

We also saw evidence monthly recorded fire checks and fire evacuation training had been carried out, enabling the organisation to monitor staff responses during evacuation procedures.

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 service could not demonstrate that equipment maintenance was consistently managed across all locations. We reviewed servicing records, including evidence of engineer servicing and ultrasound machine maintenance. Evidence was received from 3 clinic sites: Portsmouth, Southampton and Chichester. We requested data for all sites and managers stated that this responsibility sat with senior leaders and was not within their remit. The service told us it had run a systems upgrade programme between July and October 2025, during which new ultrasound systems were installed at 3 of its 6 locations and provided installation certificates for these. Maintenance across all sites reviewed was due in May 2025, but it was not performed until November 2025, representing a 6 month overdue period. This meant the service could not fully assure itself that equipment across all locations was being maintained in a timely and consistent manner, increasing the risk of undetected equipment failure.

Where evidence was available, all equipment carried up to date portable appliance testing, certification and scanning equipment including probes or serviced and calibrated in line with requirements.

The clinic demonstrated good practice in maintaining the physical safety and security of its clinical environment. This included controlled access to reception areas and doors, with staff maintaining a clear line of sight at all times. Scanning rooms contained clean, adjustable surgical beds meeting recommended standards and a dedicated quiet room was available for sensitive conversations. Fire extinguishers were accessible, serviced and correctly stored. Clinical waste was disposed of safely and secure bins under a third-party contract supported by a current and applicable waste policy. This meant that within the environment reviewed, people and the service could be reassured they were being cared for in a safe and well-maintained clinical setting.

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 could not demonstrate that all staff had completed required training and competency requirements. The gaps in oversight limited the services assurance that the workforce had the skills and knowledge to provide safe care. The service did not provide a complete mandatory training matrix. The evidence of training compliance that was provided for review was incomplete across several areas, including Infection prevention and control, and first aid.

We reviewed a small sample of staff appraisals, comprising 8 employees out of the 50 staff members reported to be employed by the service. We found that different appraisal templates had been used across the sample, resulting in inconsistencies in the appraisal process.

The service explained that, due to a change in management, appraisals had not yet been completed. The current manager, who took up post in March, advised that this work was in progress. However, no evidence was provided during the assessment to demonstrate that appraisals were being completed or monitored.

As a result, the provider was unable to demonstrate consistent oversight of staff performance across the workforce. This also meant that there was insufficient assurance that all staff delivering or supporting clinical services had been formally assessed as competent to carry out their roles safely and effectively. Staffing levels were adequate to the service being provided, and leaders demonstrated a proactive approach to maintaining safe cover. At the time of assessment, the clinic we visited was staffed by a clinic manager, scanning assistant, and sonographer who was also the registered manager. With no current vacancies, leaders planned staffing levels in response to service demand, and annual leave cover was provided through the redeployment of staff from other clinics within the service franchise. This meant people using the service could be confident that sufficient staffing was available during their attendance.

The service demonstrated professional registration and qualifications of its clinical workforce. The sonographer onsite was registered with the Nursing & Midwifery Council (NMC) and a member of the British Medical Ultrasound Society. A registration audit conducted in March 2026 confirmed that all sonographer staff across the entire service held active memberships. The service also held current insurance documentation covering employers’ liability, public liability and medical malpractice. While there is no current UK legal requirement for the title of their “sonographer” to be protected, the Society of Radiographers (SoR) states that for “safety, accuracy, and medical reliability, baby scans should only be performed by qualified sonographers, radiographers, midwives, or doctors.” The service was consistent with this standard. This meant people using the service. could be reassured that those performing scans held recognised professional qualifications and registration.

Staff told us new staff received structured induction and were supported to develop competency before working independently. Scan assistants were inducted by senior managers with exposure to all aspects of their role. Sonographers worked alongside a clinical lead at the beginning of their post to ensure practice met expected standards and to make sure that local policies and procedures were understood. Sonographer training included both face to face and online elements.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. However, the service was unable to demonstrate that its infection prevention and control governance framework was up to date or consistently implemented across the workforce.

The service managed infection risks well. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean. Staff cleaned equipment after patient contact and at the end of each working day. We saw checklists that confirmed cleaning had been completed.

The clinic was visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. There was a cleaning checklist completed daily which was checked for completion and evidence confirmed that all sites had completed both regular and deep cleaning schedules within the last 2 months. Staff adhered to bare below the elbow protocols and had access to Personal Protective Equipment (PPE) including gloves and aprons in a range of sizes in accordance with Health and Safety Executive requirements. Ultrasound probes were cleaned with sanitising wipes after each scan, and the ultrasound machine was cleaned at the end of each day. People using the service reported no issues with equipment and described the premises as “tidy and clean.”

The clinic had a dedicated Control of Substances Hazardous to Health (COSHH) cupboard which was securely locked. The service’s COSHH policy was in date with safety protocols on hazardous substances.

We did not look at Medicines optimisation during this assessment. The service did not keep, use or store any medicines. The score for this quality statement is based on the previous rating for Safe.