Ultrasound-Care Bromsgrove

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

Well-led

Well-led – 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 inspection we rated this key question requires improvement. The service was in breach of legal regulation in relation to staff Disclosure and Barring Service checks, and managers inability to access staff records. The service has made improvements and is no longer in breach of regulations. We saw staff records were easily accessible, and DBS checks were completed. At this assessment the rating has improved to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. There was a clear, shared direction and set of values understood by all staff groups. Managers were passionate about providing a high-quality service. Patients could easily access the service and there was equity across all pathways. Policies were reflective of national guidance and up to date. Supervision for substantive staff was in place and being implemented for sonographers. However, meeting minutes and the risk register were not detailed. Audits were not separate to checklists and there was limited evidence that these were discussed at a senior level.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy, and culture and they understood the challenges and the needs of people and their communities.

The service had a vision for what it wanted to achieve, which clearly outlined key objectives and developments. The service was managed by a family who shared a vision and were driven to provide a quality service. They were able to explain the aims and objectives. The values of the service were shared with the team, and there were clear expectations around these. Senior managers monitored and regularly assessed staff to ensure that values were followed in practice.

Staff spoken with had awareness of how their work contributed to achieving targets, and senior managers had specific roles and responsibilities, such as staff development, patient feedback and information technology (IT) Staff were focused on the needs of patients receiving care.

Staff felt respected, supported, and valued. Most staff had worked at the centre for several years and enjoyed working with the team. Staff reported that the leadership culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration. Staff were able to seek support or advice from managers or colleagues if needed.

Staff felt motivated about the future and planned changes for the service. They were able to support developments locally, and due to the proximity of a sister centre, were able to work across both centres if necessary. Staff were kept informed of plans for developments and knew what stage developments were at.

Team and individual staff achievements, and success was recognised and celebrated. Staff were thanked for their work. We saw that team meetings included positive staff feedback, and they were praised for their hard work. Patient feedback was also shared.

The provider had inclusive leaders who understood the context in which they delivered the service and embodied the culture and values of their workforce and organisation. However, clinical leadership was not embedded, and they were in the process of implementing clinical supervision and audits.

The service was unique in its set up, with all directors and senior managers being related. Each manager had a designated role and responsibility and supported the functioning of each site. Staff told us managers were visible.

Due to the size of the organisation, there were minimal tiers in structure. There were five directors, and they had recently developed a senior sonographer role. Their role was to assist with clinical governance. All other staff members were either substantively employed (chaperones and admin) or worked as self-employed members of staff (sonographers).

Leaders had the skills, knowledge, experience, and credibility to lead effectively. They were clearly business focused and had developed a business model which worked for them. They were able to bring in additional skills or centres following the same model. Managers understood their pathways and actively participated in all areas of the service to ensure they understood how things worked and to ensure the quality of the service. This included sonography, where one of the senior managers had received training in scanning to better understand the role.

Senior managers were developing skills and understanding of the service. Leaders had a range of experience, skills, and abilities to run the service, and they understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service for patients and staff. Staff felt the leaders supported them to develop their skills and to take on more senior roles.

Leaders spoke about potential incidents and knew how to deal with concerns when raised, which promoted a positive culture in the service. Leaders attended the service to assess for themselves how the service was running and were visible. Staff reported that senior managers were responsive to calls for help or support, and were always willing to stand in, in the event of last-minute gaps in non-sonography staffing.

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

Staff and leaders acted with openness, honesty, and transparency. Staff were encouraged raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard. Staff told us that managers were always willing to listen and supported them if there were issues with the service, often attending the centre if called.

Patients, their families, and carers were provided with information to explain how they could raise a concern and how this would be investigated. Staff were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process and staff were encouraged to ensure communication was clear. Senior managers also requested staff to contact them directly so they could support any complaints at the time.

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

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. We saw that staff meetings included ensuring staff were considerate of their peers. Staff told us they had opportunities to learn new skills in line with service developments.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act and those from excluded and marginalised groups. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

The provider had clear responsibilities, roles, systems of accountability and they used these to manage and deliver good quality, sustainable care. However, risk mitigation was not always clearly recorded or reviewed, and meeting minutes lacked detail.

Whilst the structure promoted a focused and driven leadership team, there was limitations to governance as work was always discussed openly and not just at management or team meetings. This meant that meetings, although recorded, lacked depth of detail. Due to the nature of the service, this was not necessarily a problem as the team shared goals and communicated daily.

The service had a management meeting every quarter, although they discussed business functioning and development daily. Management meetings did not have a set agenda but did discuss performance and service development. Information collected included the number of scans completed, feedback, complaints, and staffing.

There were plans to introduce a clinical lead (Radiologist) however, this was still in the planning phase.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them. The lead sonographer was responsible for updating clinical policies and reviewing clinical staff and had experience in this in their NHS role.

Staff could find the data they needed, in easily accessible formats and information systems were integrated and secure.

Leaders made sure that accurate information was discussed and shared with key staff. For example, information was shared via email or at team meetings. Due to the size of the service and regular attendance of senior managers, they were confident that information was shared quickly and effectively. Staff had to confirm understanding of any shared information by email.

Risks were clearly identified and appropriate to the service, however, there was limited evidence that these were reviewed regularly and mitigation was not always clearly recorded. The risk register did briefly outline what actions could be taken, for example, the use of a second scanner in the event of a breakdown.

Audits were not embedded, and we saw that although checklists were used to confirm actions, there were no independent audits to review aspects such as infection control and protection, handwashing, or adherence to uniform policy. Substantive staff were assessed monthly and were observed for a minimum of three patient interactions, for communication, and assisting with privacy and mobility.

The lead sonographer was in the process of introducing clinical audits, with a retrospective review of scans and a face-to-face assessment of communication, infection control, and adherence to policy.

The service had plans to cope with unexpected events and had a business continuity plan, which included major incident plans. The team were able to use a backup scanner and if the centre were unable to be used, patients could be facilitated at the sister site, which was within easy access.

The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly, and the team were reviewing electronic patient record systems to enable a paperless service. We saw that staff had secure log ins and felt that IT services were effective, and managers were very responsive to any issues.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy. Policies clearly identified actions to be taken to ensure consistency across the service.

The service did not have a business continuity plan but understood what would need to be done in the event of any unexpected disruption to the service. This included a short-term disruption plan. We found there were risk assessments for the down time of the scanners.

The provider understood their duty to collaborate and work in partnership with the services who referred into them. Information shared was timely and clear. Due to the nature of the service, there were limitations to the number of partners. However, senior managers were actively looking at ways to develop additional services with other providers and extend services.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. Referrals were reviewed and arranged with individuals at a time to suit them, and reports were clear. Senior managers recognised that there was a need for additional testing due to delays in NHS appointments and therefore provided speedy responses to requests. They had also extended their skills, by introducing a phlebotomy services, aiding diagnosis.

Senior managers did not work as part of a regional network; however, they actively tracked similar organisations and professional developments to ensure they were providing a high-quality service. Sonographers were able to share developments within their profession, and these were acted upon by senior managers.

The provider focused on innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience and a quality service. However, innovation was limited by the type of business.

Staff were encouraged to suggest new ways of working to improve services. Sonographers were all experienced and openly shared knowledge and ways of working.

Staff and leaders were committed to excellence that centred on the patient experience. Where they saw a need, they worked together to find a solution. Senior managers were present and were clear about what was expected from staff with regards to communication and the types of language used. For example, staff were encouraged to ask questions about the scans to ensure women understood images and were happy with the image before they left.