The Scan Clinic

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

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. We checked equipment and premises were suitable for the treatment and care delivered and there was appropriate maintenance.

At our last inspection we rated this key question as requires improvement. At this assessment the rating had changed to good. This meant people were safe and protected from avoidable harm. The service had undertaken work to address issues raised during our previous inspection. The service had registered with a central alerting system to receive patient safety alerts. In addition, the service had implemented appropriate systems and processes to safeguard people from abuse and had appointed a designated level 3 safeguarding lead for children and adults.

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.

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 managed safety incidents well and learned lessons from them. The service had a clear process for reporting and learning from incidents. Staff reported incidents on a significant events and incidents log. We viewed examples of incidents and saw these were investigated, lessons were identified and improvement implemented.

We saw evidence lessons were learned and shared with all staff. We reviewed an incident investigation form from August 2025. This involved a blood sample which could not be processed due to missing information (date of birth). The service reiterated the need for all staff to double check laboratory forms before sending samples.

The service followed the duty of candour policy by disclosing incidents to service users and providing feedback on investigation outcomes when necessary. We reviewed three incident investigation reports, and all included clear action plans.

The service conducted annual audits of significant events and incidents recorded. The audit for the period covering January to December 2024 showed staff had complied with standards for recording events, classification and grading, action timelines, appropriate actions, and learning.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Staff shared key information to keep service users safe when handing over their care to others. The service liaised with GPs, local trusts and maternity units to support referrals were necessary.

Staff made it clear to pregnant women and birthing people that scans completed at the service were in addition to those provided as part of their NHS maternity care pathway and they still needed to attend their NHS care. The service had a clear pathway for early pregnancy referrals should they find an anomaly during pregnancy scans. Staff were clear on the referral process.

The service worked seamlessly with a private laboratory for the provision of blood tests and results.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff received training specific for their role on how to recognise and report abuse. Staff had completed the right level of safeguarding training for both children and adults. All clinical staff had completed level 2 safeguarding training while senior staff had completed level 3 safeguarding training.

Staff we spoke with knew how to identify people at risk of, or suffering, significant harm or abuse and the service worked with other agencies to protect them. Staff could give examples of how to protect service users from harassment and discrimination, including those with protected characteristics under the Equality Act.

The service had a safeguarding policy with clear guidelines on how to make a safeguarding referral and who to inform if they had concerns. The registered manager served as the safeguarding lead and had completed level 3 safeguarding training for both adults and children.

The service had a female genital mutilation (FGM) policy which referenced the department of health’s FGM risk and safeguarding guidance document.

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.

Staff completed individual risk assessments which included service users’ medical history including details of any surgery or cancer diagnosis, and allergies. The service provided supplementary scan services for pregnant women and birthing people. Pregnant women and birthing people were required to have registered with maternity services.

There was a clear criteria for service users seen at the service. The service did not provide services to service users who required emergency or acute care.

The service had a clear care pathway to escalate the care and treatment of service users based on ultrasound findings. Staff had access to clear guidelines which categorised ultrasound results into critical, urgent, significant and routine findings. For example, ultrasound scans showing live ectopic pregnancy were classified as critical findings. This required immediate transfer of the service user to secondary care/ accident and emergency with the results marked as “urgent”. A copy of the result was also sent to the service user GP on the same day.

The service had clear guidelines for the escalation of service users who may require urgent medical care. This included calling an ambulance. The service had three first aiders who had completed training to provide immediate care until professional medical care could be obtained. Clinical staff had completed basic life support training on how to manage life-threatening emergencies.

At our last inspection, we identified that the service was not registered with the central alerting system (CAS) to receive patient safety alerts. At this assessment, the service had registered with CAS and kept a CAS alert log to update staff on patient safety alerts.

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 followed national guidance and had suitable facilities and equipment to support the delivery of safe care. The Scan Clinic was located on the first floor and had a private secure entrance with video surveillance. All equipment we reviewed, conformed to the relevant safety standards, and had been serviced annually. The service had a contract with the manufacturers of the ultrasound scan machine to maintain and service the machine. Fire extinguishers were serviced yearly and were in date for servicing. Staff had received training to use equipment.

There were adequate arrangements for handling, storage and disposal of clinical waste, including sharp instruments.

The service completed annual health and safety compliance audits through an external health and safety service provider. The audit report from August 2025 evaluated several risks including electric safety, fire safety, office hazard, chemical safety, equipment and machinery, building safety, disposal of waste and first aid among others. Risks were either rated low or very low and an action plan was implemented to address issues highlighted in the report.

The service conducted an annual friends and family test audit. The latest feedback audit showed that the service achieved an average score of 4.7 (out of 5) for the question “was the environment clean?”

The service was situated on the first floor, and the building did not have a lift; it did not have wheelchair access. This meant the service could only screen service users who could access the service without a lift. Staff informed us they referred service users who could not access the service to other providers.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

The service had enough imaging and support staff to keep people safe. Daily staffing rota consisted of 1 clinical staff member, 2 administrative or clinical assistants and one general manager.

The service employed 2 sonographers (including the registered manager), 4 phlebotomists, 3 administrative staff and a general manager. The registered manager acted as the clinical lead and was registered as a radiographer with the Health and Care Professions Council (HCPC).

Staff had completed mandatory training required for their role. This included training regarding consent, controlled drugs, health and safety, moving and handling, equality, diversity, inclusion and human rights, deprivation of liberty safeguards, accident and incident reporting, conflict resolution, infection prevention and control, complaints, record management, hand hygiene, cyber security, information governance, mental capacity act, safeguarding children, safeguarding adults, paediatric basic life support level 2, adult basic life support level 2 and basic life support level 1.

The service conducted recruitment checks including employer references and disclosure and barring service (DBS) checks. This was also reviewed regularly to make sure they were up to date.

All staff had completed an induction training when they newly joined the service. Staff had received an annual appraisal in the last year.

The service assessed and managed the risk of infection.

We observed that all areas of the service were visibly clean and free from clutter. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.

There were enough hand washing sinks available, in line with the Health Building Note (HBN) 00-09: Infection control in the built environment. Soap and disposable hand towels were available next to sinks and instructions on how to effectively decontaminate hands were displayed above the sinks.

Staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our inspection, such as hand washing and using hand sanitisers when entering and exiting the unit and wearing personal protective equipment when caring for service users. Staff also disinfected the probe before and after use. We found the process of decontamination of probes to be thorough and robust.

The service provided a hand hygiene audit from March 2025. The hand hygiene audit tool used indicated, that all staff should be assessed for hand hygiene techniques on at least an annual basis. The audit observed two staff member’s compliance with infection prevention and control (IPC) guidelines.

The results of the hand hygiene audit indicated that staff did not always take the opportunity to clean their hands at ‘key moments’ in line with the World Health Organisation’s (WHO) “5 Key moments for hand hygiene”. This required staff to clean their hands at 5 key moments including before patient contact, before a clean/aseptic procedure, after body fluid exposure risk, after patient contact and after contact with patient surroundings.

An action plan was completed following the hand hygiene audit which involved discussing appropriate techniques with affected staff. However, this did not include a plan to conduct a re-audit or increase the frequency of hand hygiene audits to ensure consistent compliance.

The service achieved 93% compliance in an infection control audit carried out in June 2025. The infection control audit reviewed the availability of appropriate policies, organisational structures, facilities, supplies, and equipment to facilitate compliance with guidelines on hand hygiene. The audit also covered the environment, the kitchen area, toilet area, waste disposal, personal protective equipment and decontamination.