Elite Community Ultrasound

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• 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

This was our first assessment of this service. This key question was rated requires improvement.

Safeguarding policies were not always aligned with national guidance, did not always contain accurate contact details, and safeguarding training was not completed consistently. The registered manager was the only sonographer employed by the service, and there was limited evidence of appraisal, competency assessment and independent clinical oversight, which presented a risk to the resilience of staffing arrangements and ongoing assurance of clinical practice.

However, the service provided care in a clean environment and had effective infection prevention and control arrangements. Equipment and fire safety systems were appropriately managed, and there were clear processes for responding to unexpected scan findings, medical emergencies and the transfer of care where required. Staff were encouraged to report incidents and share learning from incidents to support service improvement.

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. Whilst staff understood how to raise and report safety concerns, processes were not clear on how patient safety incidents should be identified, reported and learned from.

The service had a policy in place for reporting and investigating accidents and incidents. However, the policy focused primarily on workplace accidents, staff injuries and compliance with Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) requirements. It did not provide guidance on the identification, reporting, investigation and learning from patient safety incidents. The policy lacked clear processes for recording clinical incidents, near misses, safeguarding concerns and incidents affecting people using the service. It also did not set out how incidents would be reviewed, how lessons learned would be shared with staff, or how themes and trends would be monitored to improve safety and quality of care.

The service had not reported any patient safety incidents in the year before the assessment. However, processes were in place to identify, report and manage patient safety incidents should they occur.

Staff told us they had not needed to report any incidents but understood what to report and how to raise concerns. This involved recording incidents in an incident log book kept at the clinic reception desk.

The registered manager described an occasion where a visitor had nearly fainted while at the clinic. Staff responded appropriately but the event was not recorded in the incident log book.

Staff understood the duty of candour. They described how they would be open and transparent with patients and their families if something went wrong.

We saw evidence that the service responded to the small number of negative comments received and used these as opportunity for learning.

We scored the service as 2. The evidence showed some shortfalls. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had systems and processes to ensure patients received care that met their needs and were referred appropriately when their needs fell outside the scope of the service.

The service had eligibility and exclusion criteria to support safe decision-making about which patients could access the service. The criteria stated that patients must be aged 18 years or over, be able to provide informed consent and not require immediate emergency NHS intervention. However, the service had amended its user age bands to accept and scan young people aged 16 to 18 years. This meant the eligibility criteria did not reflect the service's current practice and required updating. Additional criteria were in place for pregnancy scans. Patients experiencing symptoms such as severe abdominal pain, heavy vaginal bleeding or suspected ectopic pregnancy were not accepted for scanning and were directed to appropriate NHS services.

Processes were in place to ensure that essential patient information was obtained in advance of appointments, to help staff determine if the patient’s needs could safely be met. People’s needs were assessed using a medical questionnaire, completed by the patient before each appointment. However, the registered manager told us the service did not undertake any additional risk assessments when scanning patients aged under 18 years. Staff relied on the same processes and assessments used for adult patients. This was not in line with good practice, as children and young people can have different physical, emotional and safeguarding needs which require specific consideration. The provider had not assessed the potential risks associated with providing services to patients aged 16 to 17 years and could not demonstrate that appropriate arrangements were in place to ensure care was tailored to this patient group.

The service had processes to respond to unexpected or significant findings identified during ultrasound examinations. Staff advised patients with urgent concerns to attend early pregnancy units (EPU) or local emergency department. With patient consent, staff could also contact the patient's GP, midwife or local hospital to support appropriate referral and signposting for ongoing care.

The service had a referral and escalation policy that identified symptoms and findings requiring urgent action. This included a referral criteria document that described red flag symptoms requiring escalation, including heavy bleeding, reduced foetal movements and significant pain.

The registered manager told us that the service did not confirm a diagnosis of miscarriage following a single scan. As the registered manager was the service's only sonographer, patients with findings suggestive of miscarriage were referred to their local Early Pregnancy Assessment Unit (EPAU) for further assessment and confirmation of the diagnosis. The registered manager advised patients to contact the EPAU directly or offered to contact the service on their behalf. This supported timely access to appropriate follow-up care.

The service had a medical emergencies policy that described the actions staff should take if a patient became acutely unwell. The policy required all clinical staff to complete basic life support training, and training records confirmed this requirement had been met. The policy instructed staff to contact emergency services in the event of a patient collapse or loss of consciousness and to complete an incident report following the event.

Staff shared key information to support continuity of care. Patients received electronic access to their scan images and reports, and staff could share information directly with healthcare professionals, with the patient's consent. Where necessary, staff contacted relevant healthcare professionals by telephone to escalate concerns.

However, while the service had referral, escalation and miscarriage management procedures, these documents did not consistently reference recognised national guidance or evidence-based standards. In addition, the miscarriage management procedure did not include details of local referral services, such as EPAU or emergency department contact information. This meant the provider could not demonstrate that all clinical pathways had been developed with reference to current national guidance and local referral arrangements.

We scored the service as 1. 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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

The service had safeguarding policies which contained inaccuracies and outdated information that had the potential to prevent staff from accessing current safeguarding contacts and follow appropriate information-sharing practices. Hyperlinks within the documents were broken and did not direct staff to the referenced guidance.

The service’s safeguarding adults policy identified a named doctor as the safeguarding lead. However, this individual was no longer working for the service. The registered manager told us they were the safeguarding lead. The policy also included details of local safeguarding contacts, but the link provided directed staff to a safeguarding webpage for a London-based authority rather than the safeguarding partnership relevant to the service’s location. As a result, staff may not have been able to readily access accurate local safeguarding referral information.

The service’s safeguarding children and young people policy stated that consent was required before sharing safeguarding information. This did not reflect safeguarding best practice, as professionals may share information without consent where there are safeguarding concerns and doing so is necessary to protect a child or vulnerable adult from harm.

The service could not demonstrate that all staff had completed safeguarding training appropriate to their roles.

Although 2 of the 4 reception staff had completed Level 2 safeguarding training for both adults and children, the service was unable to provide evidence that the remaining 2 staff had completed safeguarding training. As a result, leaders could not be assured that all staff were equipped to recognise and respond to safeguarding concerns in line with the service's policies.

The registered manager as safeguarding lead was not trained to level 4 safeguarding children. This is not in accordance with the intercollegiate document Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff (2019).

Leaders could not clearly describe arrangements for accessing Level 4 safeguarding support or supervision if required. Although the safeguarding policy stated that independent safeguarding advice was available, it did not clearly define these arrangements.

However, the service’s safeguarding children and young people policy identified the registered manager as the safeguarding lead and included links to the appropriate local authority safeguarding referral processes.  The policy also made clear that the service did not provide treatment to people under the age of 18, however data provided by the service showed that 23 young people aged 16 – 18 had been scanned by the service in the last 12 months. This meant the policy did not reflect the service's current practice and required updating.

The registered manager had completed Level 3 safeguarding training for both adults at risk and children at risk, which was appropriate for their role of sonographer. Staff also demonstrated an understanding of safeguarding responsibilities and described how they would recognise and escalate safeguarding concerns.

Staff had not made any safeguarding referrals in the 12 months before our assessment.

Staff completed chaperone training and the service displayed signs in the reception area informing patients about requesting a chaperone. Most of the reception staff (3 out of 4) had completed chaperone training. This was in line with the service’s chaperone policy and the Society of Radiographers and British Medical Ultrasound Society’s ‘Guidelines for Professional Ultrasound Practice’ (2023), which states that “chaperones should be trained in the role”. Untrained chaperones may not fully understand their responsibilities, potentially leading to inadequate safeguarding and support during intimate examinations.

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.

Staff communicated with patients in a way that helped them understand their care and treatment. We observed the sonographer explain the procedure clearly, including what it would involve, its purpose, any limitations, and how results would be communicated. The sonographer checked their understanding to make sure they were fully informed before proceeding.

We observed the sonographer check 3 patient identifiers to ensure the correct person received the correct ultrasound examination. We reviewed an identification check audit completed in May 2026. The audit examined 30 patient records to assess whether patient identity had been appropriately verified and documented prior to scanning. The audit found that 100% of records contained the patient’s full name and date of birth. However, it identified areas for improvement relating to documentation of identity verification and the recording of photo identification checks. Actions had been identified to address these findings, and a re-audit was planned to monitor progress and ensure improvements were embedded into practice.

We reviewed a pregnancy check audit completed in May 2026. The audit examined 30 patient records to assess where pregnancy related scans were performed safely and in line with clinical guidance. The audit found that no scans were performed outside clinical suitability and that urgent escalation was completed appropriately. Areas for improvement were identified around documentation of signposting provided to patients, including instances where patients had been advised to contact the early assessment unit (EPAU) or NHS maternity triage service. Actions had been identified to address these findings.

Patients who self-referred for screening and non-invasive pre-natal testing (NIPT) were provided with standard information and leaflets, in line with National Screening Committee (NSC) guidance. This supported patients to make informed decisions by providing information about the purpose, benefits, limitations and potential outcomes of testing.

The service had processes to respond to unexpected or significant findings identified during ultrasound examinations. Staff advised patients with urgent concerns to attend their local NHS emergency department, and where consent had been obtained, contacting the patient’s GP, midwife or local hospital to support appropriate follow-up care. The registered manager told us that where patients choose not to follow the advice provided, this was documented within the patient’s record. The service also had a referral criteria document that identified red flag symptoms requiring urgent escalation, including heavy bleeding, reduced foetal movements or significant pain.

Staff did not have access to patients’ medical records and relied on patients sharing their own medical information and history.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service maintained facilities, premises and equipment to support safe care. The service operated from a clean and well maintained environment with a staffed reception area during opening hours. There was a scanning room, staff office and toilet facilities, all located on the ground floor.

The service used an ultrasound machine which included a transvaginal probe for internal examinations. The scanning room was clean, bright, and well-lit. The room was large enough to allow patients to prepare for their scan and privacy screens were provided. Staff provided patients with modesty covers when intimate scanning was required.

Staff stored clinical equipment and consumables appropriately and maintained them in good condition. Staff checked consumables remained within their expiry dates. Available stock included 5 sterile, single-use transvaginal scan probe covers, 20 unopened bottles of ultrasound gel, a range of sterile and non-sterile gloves, and 5 individually packaged sterile gauze packs.

The service had appropriate fire safety arrangements. Equipment was available and appropriately maintained. Fire extinguishers were located at entry and exit points, were securely mounted, and were within their service dates. The service displayed clear fire evacuation plans to provide guidance for staff and visitors.

We saw evidence that an external company had been hired to provide a fire risk assessment of the premises.

Patient mobility was checked prior to the appointment to enable staff to prepare for patients who needed assistance. This included the use of a temporary ramp to access the building if necessary.

We saw evidence that portable appliance testing had been completed for the area.

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. However, they did work together well to provide safe care that met people’s individual needs.

The provider could not demonstrate that robust arrangements were in place to oversee, support and assess the performance of all staff.

Until April 2026, the registered manager was the sole sonographer employed by the service. In April 2026, the service appointed a bank sonographer to support service delivery. Following the assessment the registered manager had also recruited a second member of bank staff and one permanent member of staff. This demonstrated that leaders recognised the staffing challenge and had taken action to increase workforce capacity. However there was still limited opportunities for peer review, clinical audit and professional challenge within the service.

The registered manager covered clinics across this location and 2 additional locations. They tried to ensure availability at each site across the week by travelling between the sites on different days for morning or afternoon clinics depending on demand. Following the assessment, the registered manager told us that a bank sonographer had recently completed their induction, which increased the service's sonography capacity.

The provider did not maintain written records of competency reviews or competency assessments for sonographers. This was not in line with the service's Ultrasound Policy, which stated that audits should be carried out quarterly on the work of all ultrasound practitioners. Whilst the registered manager was no longer the only sonographer employed by the service, there was no evidence that arrangements were in place to independently review, quality assure or audit their clinical practice.

The registered manager had not received formal appraisals, one-to-one performance reviews or clinical supervision. The provider had not established arrangements to ensure the registered manager's performance, development needs and clinical practice were subject to regular oversight and review.

The service's induction documentation had not been fully tailored to reflect the scope of the service. For example, the induction pack included references to domiciliary visits, prescribing arrangements and coroner notification processes, despite these not being relevant to the services provided.

The provider submitted appraisal compliance data; however, the information provided was not clear and contained inconsistencies. For example, the data stated there were 2 members of the human resources team, with one appraisal completed, yet this was recorded as a 100% completion rate. The data also indicated that the registered manager had received an appraisal. However, the provider was unable to demonstrate who had undertaken this appraisal, as there was no clinical lead, director, or other senior individual within the organisational structure with responsibility for overseeing and appraising the registered manager's performance. This meant the provider could not provide assurance that appraisal arrangements were robust and subject to appropriate oversight.

However, the service employed staff with the qualifications, skills and experience required for their roles. In addition to the registered manager, the service employed 4 administrative staff, 1 of whom was also a trained phlebotomist, as well as an off-site human resources staff member.

The service maintained appropriate recruitment records. Staff files contained the required recruitment checks and supporting documentation.

Staff received and were up to date with some mandatory training topics. Mandatory training included topics such as consent, infection prevention and control, and adult basic life support.

The data provided by the service indicated that most administrative staff had received an appraisal.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

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 kept the location visibly clean and free from clutter. They made sure furnishings were suitable, clean and well-maintained. The service contracted a third-party cleaning company to clean the area weekly.

The service made sure that general waste was appropriately disposed of in designated general waste bins. Staff correctly segregated and disposed of clinical waste generated during procedures in the appropriate clinical waste containers.

The service made sure that personal protective equipment was readily available for staff. Staff were observed using personal protective equipment appropriately during patient care activities. Staff complied with the bare below the elbows requirements while working in clinical areas. The service provided access to suitable handwashing facilities, and hand sanitising gel was available throughout the clinical environment to support effective hand hygiene practices.

For abdominal ultrasound examinations, staff removed ultrasound gel using disposable paper towels and cleaned the probe and cable before and after each patient examination using approved disinfectant wipes.

For transvaginal (TV) ultrasound examinations, staff used a sterile probe sheath for each patient. Following each examination, staff decontaminated the probe using the recommended cleaning product and a descending cleaning technique.

The service maintained records relating to the cleaning, disinfection and traceability of transvaginal ultrasound probes, and records covering the period from March to May 2026 were reviewed.

However, the records did not include the serial numbers of the probes used, which meant the service could not demonstrate full traceability of individual devices in the event of an incident, equipment failure, or infection prevention and control concern.

The service provided an infection prevention and control audit following the assessment. The audit included a hand hygiene review that assessed 11 measures, including compliance with bare below the elbows requirements, whether hand hygiene was performed before and after patient contact, and whether correct handwashing techniques were used.

We scored the service as 3. The service did not store or administer any medicines or controlled drugs.