Ultrasound Direct Southwest Coast

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• 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.

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

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 lacked a clear vision and strategy to drive improvement. There was a disconnect between leadership and the rest of the workforce. Staff said they did not feel involved in wider team meetings, and said discussions about service direction were largely limited to senior leadership level. This meant staff were not consistently engaged in shaping improvements or translating stated ambitions into meaningful change.

The service had arrangements in place to recognise staff, including an “Above and Beyond“ award, congratulatory emails following positive client feedback, and funded staff social events and communicated with staff through a newsletter.

However, staff morale was not consistently maintained across the workforce. Multiple survey respondents described team morale as low, with some staff reporting feeling unsupported by senior leadership despite having a positive relationship with immediate colleagues.

The service had a vision centred on delivering high quality private ultrasound services, and evidence demonstrated awareness of commercial objectives and growth targets. Online review scores across the region were consistently high ranging from 4.8 to 5 stars, which indicated a positive patient caring culture.

However, there was limited evidence showing how patient outcome data was regularly analysed to identify and address health inequalities. While some reasonable adjustments were available, the service could not fully demonstrate how information relating to protected groups was used to drive service improvement.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

The service could not demonstrate that senior leadership consistently modelled a positive and inclusive culture. Evidence from their recent anonymised staff survey identified significant and repeated concerns about the behaviour of senior leaders, with multiple staff members describing feeling “unsafe “and “devalued” following interactions with them.

Leadership visibility had a negative impact on staff wellbeing. Staff reported that interactions with senior leaders had left colleagues emotional and some staff choose not to engage with them directly, leaving others to act as intermediaries.

The service published its rota in advance and staff on casual worker agreements were not required to accept hours offered to them. However, staff described zero hours contracts as ‘exploitative’ with added pressure to be available outside or agreed hours. The service did not demonstrate that it had understood or responded to these concerns.

The service had not fully demonstrated that concerns raised through staff feedback were acted upon in a timely way. We reviewed 8 franchise meetings from January 2025 to March 2026 and there was limited evidence that the themes identified through the staff survey had been systematically reviewed, escalated or resolved.

The service had a sonographer competency framework that set out the knowledge, skills, and tasks required for the role and included sign-off by both the trainee and trainer upon completion. However, the service did not provide completed competency records for staff. In addition, revised onboarding and competency documents for sonographers and Client Support Specialists were still in development and had not been finalised at the time of the assessment. As a result, the service could not fully assure itself that staff were competent to undertake all aspects of their roles.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

The service had a whistleblowing policy, that was current and in date.

However, the service could not demonstrate that the whistleblowing policy was embedded in practice or known to staff. The whistleblowing policy was effective from April 2026, however there was no evidence that staff had read or been made aware of the updated policy and no evidence that training on whistleblowing had been completed by any member of staff.

The whistleblowing log was empty, meaning the service could not demonstrate that any concerns had been raised, recorded or responded to through formal process. The empty whistleblowing log was inconsistent with the concerns identified in the staff survey. Survey responses described a culture where staff felt “unheard”, “disposable” and “disrespected” in interactions with senior leaders. This indicated a working environment that was not consistently psychologically safe, which was a barrier to effective speaking up.

Also, the Freedom to Speak Up policy presented during the onsite assessment was out of date, with the most recent staff read receipts dating back to May 2024. Only 20 out of the 57 evidenced staff had read this policy. This meant that some staff had no engagement with speaking up processes for almost 2 years and the service could not assure itself that staff understood the process for raising concerns safely and confidentially.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce but did not demonstrate that EDI principles were consistently lived and embedded in the culture of the service

The service had an in-date equality, diversity and inclusion (EDI) policy and there was evidence that all staff had read it. This demonstrated a baseline awareness of EDI responsibilities across the workforce.

The service demonstrated positive recognition of staff contribution. Evidence from franchise meetings identified an “above and beyond “recognition scheme, whereby staff achievement was valued and celebrated at an organisational level.

However, the service could not demonstrate how workforce EDI data was monitored or used to drive improvement. There was no evidence that the diversity of the workforce was formally analysed, that EDI outcomes were reviewed at governance level or that any identified disparities had been addresses through targeted action.

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.

Governance processes were not effective. There was limited evidence to show that information gathered through these processes was used to drive meaningful improvements.

For example, the audit tools the audit tools were not effective. In the sections for key themes identified, actions, recommendations and date for re-audit had been left blank. This meant that even where issues were found, there was no record of what had been done about them and no plan to check whether things had improved.

The audit activity was insufficient to demonstrate that it regularly checks and tracks outcomes in a consistent way. Several audit records lacked dates or sufficient detail to confirm the integrity or effectiveness of the audit process. For example, scan image quality audits were provided but did not include dates of when audits were completed, meaning the provider could not demonstrate this activity was being conducted regularly or that findings were being acted upon in a timely way. No evidence relating to clinical documentation audits was provided. This meant the service could not show that its audits were thorough or consistent enough to help improve quality.

Also, the clinical governance report contained actions that remained outstanding, and there was no evidence that themes from incidents or staff feedback had been brought together to drive change at a service level.

The service did not effectively manage or monitor identified risks to provide assurance that risks were reduced or controlled. Although the risk register was being used and contained dated entries with named actions and leads, not all risks had been followed through to completion. For example, a risk relating to General Data Protection Regulations (GDPR) non-compliance was recorded on 23 February 2026 with an inherent high-risk score of 12, identifying the potential for patient data to be shared incorrectly through manual paper-based processes. A plan had been developed to provide staff training. However, the residual risk score had not been completed at the time of the assessment. This meant the service had no way of knowing whether the steps taken had reduced the risk. Also, there was no evidence that staff had received GDPR training or that there was an in date GDPR policy. This was a concern because the service held sensitive and confidential information.

The service did not have effective governance arrangements in place to oversee data protection. Evidence reviewed during the assessment indicated that the service was unable to identify a designated Data Protection Officer (DPO). Given that the risk register had already identified GDPR non-compliance as a significant risk, the absence of a named lead with responsibility for this area meant there was no clear accountability for keeping people’s data safe. The risk register did not include any risks relating to the accessibility needs of people using their services, including those with mobility and communication difficulties. This meant the service had no documented plan for how it would identify and respond to the needs of patients who may require additional support to access or use the service safely.

The service did not ensure its policies were current, regularly reviewed or fit for purpose. The service had several policies that were out of date at the time of assessment. When this was raised with managers, they stated that senior leaders at the franchisor’s headquarters were aware and would implement the necessary changes. However, no evidence of communication or formal requests to support this was provided. The responsibility for ensuring policies are current and fit for purpose, sits with the registered provider in-line with CQC’s requirements. The service could not show it had taken sufficient steps to address this.

The service could not demonstrate that its infection prevention and control governance framework was current or consistently applied across its workforce. The IPC policy was overdue for review since April 2025, meaning the policy framework staff were expected to work within may not have reflected current national guidance. Six out of 27 staff had not completed IPC training, representing a gap in assurance that all members of the workforce had the knowledge required to maintain safe standards. The service reported employing a total of 50 active staff, therefore there was no evidence of training for the remaining 23 staff members.

The COSSH waste management statement of purpose had last been reviewed in 2018 and was overdue for an update. The phlebotomy policy was not in date and had been due for a review 2 years prior, with no guidance documented on the safe storage of blood samples.

The service did not have effective safeguarding systems to identify, monitor, record and learn from safeguarding concerns, which meant leaders could not demonstrate they were meeting their safeguarding responsibilities. When we requested records of safeguarding concerns, outcomes and learning outcomes, leaders told us that cases had been passed to the NHS and that no further action had been required. There were no record of referral outcomes and no evidence that learning had been identified or shared from these cases. The services view that responsibility passed entirely to the NHS once a referral was made showed a limited understanding of their own safeguarding duties.

The service provided a full list of active staff which identified 50 people working across the service within the 6 clinics. However, some of the records provided did not account for all staff members. Leaders advised us that 22 staff members were sessional workers whose mandatory training had been completed through their NHS employer, while a further 28 staff members completed mandatory training through the service’s own training system.

However, the service’s Mandatory Training Audit (updated March 2026) recorded no courses assigned and no courses completed for 23 of the 25 NHS sessional staff listed, despite showing 100% compliance for these individuals. Evidence also showed that 2 NHS sessional staff members had completed training assigned through the service’s training system, indicating an inconsistent approach to recording and monitoring mandatory training.

We requested evidence of mandatory training compliance rather than audit summaries; however, the service was unable to provide records demonstrating that all staff had completed the required training. For example, safeguarding training records were only provided for 25 staff members. No safeguarding training records were available for the remaining 25 staff members.

This meant that the service was unable to provide assurance or evidence of the mandatory training compliance status for all staff members working across its locations.

The service did not maintain effective staff appraisal arrangements for all staff. The appraisal records from January 2026, showed that some staff had never had an appraisal, several had not responded to requests for one in 2025, and at least one appraisal had not taken place since November 2023. Significantly, the director had no recorded appraisal. The absence of an appraisal for the most senior staff member in the service meant there was no formal oversight of their fitness to lead.

The service had no clinical supervision arrangements for sonographers. This meant that there was no formal process for reviewing, supporting or overseeing the clinical work of sonographers on a regular basis. Without this, the service could not assure itself that the standard of clinical practice was being maintained across the team.

Staff turnover was high. 15 staff members left between June 2025 and March 2026, almost all through resignation. This included 2 regional clinic managers leaving within a short period of time. The service had not analysed why staff were leaving or looked at whether there were patterns that needed to be addressed.

The service had a competency framework for clinical assistants which set out a clear progression from witnessed to supervised to independent practice. The framework identified mandatory training requirements for staff.

However, the service could not show that all staff had completed the required sign offs. Competency documents for sonographers were still being developed at the time of the assessment, meaning the service could not fully demonstrate that all clinical staff were formally assessed as competent to carry out their roles.

Also, governance was not effective in providing assurance that equipment maintenance was consistently managed across all locations. Oversight arrangements failed to ensure timely servicing, with no centrally coordinated monitoring or accountability for maintenance compliance.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service demonstrated partnership working with external organisations to expand the range of services available to people. Evidence included relationships with blood testing providers and referral pathways supporting patient care. The referral pathway to the bloods service was clearly documented. People using the service were advised to expect results withing 5 to 7 working days and there was an option to have results reviewed by a GP. This demonstrated some attention to the persons journey and ensuring people received support when their results were ready.

Due to the nature of this service, the evidence of partnership working was limited to the blood service.

However, there was no evidence that the service had developed relationships with the local community organisations or patient groups to better understand the needs of the population it served.

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.

The evidence of learning and improvement across the wider service was limited. Although we had reviewed the service's safeguarding records, there was no record of the outcomes of referrals. In addition, we found no evidence that lessons learned from these cases had been identified, shared with staff, or used to support quality improvement, shared, or used to inform practice. The whistleblowing log was empty and staff survey results had not been used to make visible improvement to the working environment.

We found some evidence of a learning culture within the service, with systems such as the clinical governance report, risk register, and staff survey to support oversight and reflection. These mechanisms indicated an intention to monitor performance, identify risks, and gather staff feedback. However, these tools were not being used consistently to turn what was found into meaningful action and improvement. Innovation was evident in the new blood testing service, but this was not yet matched by the same level of attention to leaning from things that had gone well.