Elite Community Ultrasound

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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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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

The service was in breach of the regulation for good governance.

Governance systems were not always effective. Policies and procedures were not consistently reviewed and adapted to reflect the service, clinical audit processes were not sufficiently developed, and ultrasound examinations and reports were not subject to regular quality assurance review.

The provider had not identified all relevant risks, including those associated with reliance on limited sonographer capacity at the time of our assessment, and some reporting and oversight arrangements were not in line with current guidance. Although governance meetings took place and the registered manager was focused on developing and improving the service, systems for monitoring quality, safety and performance required strengthening.

However, the registered manager was experienced and compassionate. Staff described positive working relationships and told us they felt respected, listened to and able to contribute to improvements within the service. There were policies in place to support staff wellbeing and speaking up, although some policies had not been fully tailored to the service.

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 looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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

The service was in breach of the regulation for good governance.

Governance systems were not always effective. Policies and procedures were not consistently reviewed and adapted to reflect the service, clinical audit processes were not sufficiently developed, and ultrasound examinations and reports were not subject to regular quality assurance review.

The provider had not identified all relevant risks, including those associated with reliance on limited sonographer capacity at the time of our assessment, and some reporting and oversight arrangements were not in line with current guidance. Although governance meetings took place and the registered manager was focused on developing and improving the service, systems for monitoring quality, safety and performance required strengthening.

However, the registered manager was experienced and, compassionate and committed to providing high-quality care. Staff described positive working relationships and told us they felt respected, listened to and able to contribute to improvements within the service. There were policies in place to support staff wellbeing and speaking up, although some policies had not been fully tailored to the service.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Due to the small size of the organisation, there were minimal tiers in structure. The service was made up of a sonographer, who was also the registered manager, 4 administrative staff and an off-site human resources staff member.

The registered manager demonstrated a strong commitment to the service and was passionate about delivering high-quality care. Throughout the assessment, they displayed a caring and patient-centred approach towards people using the service and their partners.

We observed the registered manager communicating effectively, listening attentively to concerns and questions, and ensuring people were given sufficient time to discuss their needs without feeling rushed. Staff described an open and supportive culture in which questions and feedback were encouraged.

During the assessment, a patient was significantly delayed due to road closures. The registered manager instructed the receptionist to reassure the patient that there was no need to worry or rush and that they would still be seen on arrival. This demonstrated a flexible, compassionate approach that placed the needs of people using the service at the centre of care delivery.

We also observed the registered manager interacting respectfully and professionally with administrative staff, promoting a positive and supportive working environment. The registered manager [GF1] was visible in the service and approachable for both patients and colleagues. Staff provided examples of suggestions they had made which had been listened to and implemented, demonstrating that the registered manager valued contributions and feedback.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff described an open and supportive culture in which they felt able to raise concerns.

The service had an up-to-date Freedom to Speak Up policy which outlined when and how staff could raise concerns. The policy described internal and external routes for speaking up and demonstrated an understanding of the potential difficulties of speaking up in a small organisation. The service also had a whistleblowing policy available to staff.

However, this had not been appropriately reviewed or adapted for the service. We found more than 10 references to another organisation within the document. This meant the provider could not be assured that staff had access to clear, and service-specific guidance on raising concerns.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The registered manager described a culture where people were treated fairly and with respect. On the day of the assessment, we observed positive and professional interactions between the lead sonographer and reception staff. Communication was respectful and supportive, demonstrating positive working relationships.

The registered manager made reasonable adjustments for colleagues when requested to support them in carrying out their role. This demonstrated a willingness to recognise and respond to individual needs within the workforce.

Due to the small size of the service, formal mechanisms such as staff surveys or equality and diversity champions had not been established. The workforce consisted of the registered manager and a small team of colleagues who worked closely together. Staff told us they felt comfortable raising concerns, sharing feedback and discussing any issues directly with the registered manager. All the people we spoke with during our assessment told us they were treated fairly and with respect.

Some people working at the service had completed equality, diversity and human rights training. The registered manager had also completed training in learning disability and autism, as well as equality and diversity. However, not all colleagues had undertaken this training.

The provider policies did not include equality impact assessments to determine whether they might unintentionally disadvantage individuals or groups based on protected characteristics.

1. 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.

The provider had not established a structured programme of regular audits to assess the quality of care provided. This included the absence of audits of ultrasound examinations and corresponding reports.

The Society and College of Radiographers (SCoR) and the British Medical Ultrasound Society (BMUS), in their Guidelines for Professional Ultrasound Practice (2023), recommend that at least 5% of ultrasound examinations and reports are subject to peer review and audit. Without such audits, the provider could not be assured that image quality and reporting standards were consistently maintained, increasing the risk that errors or areas for improvement would not be identified and addressed.

The provider's health safety and risk policy referred to the former Serious Incident Framework and National Patient Safety Agency (NPSA) reporting arrangements. These frameworks have been superseded by the Patient Safety Incident Response Framework (PSIRF) and the Learn from Patient Safety Events (LFPSE) service.

The provider had not updated the policy to reflect these changes, resulting in the use of outdated terminology and references. This meant the provider could not be assured that it’s guidance for incident reporting, investigation and organisational learning was fully aligned with current national patient safety guidance and best practice.

The provider maintained a risk register which included identified risks, assigned risk owners, potential impacts and mitigating controls. However, the risk register was not fully effective in identifying operational risks that could affect service delivery. For example, at the time of the assessment, the registered manager was the only sonographer employed by the service. The provider had not identified the reliance on a single sonographer as a risk on the risk register, despite the potential impact on appointment availability and service continuity if the registered manager was unable to work. We did not see documented controls or contingency arrangements recorded on the risk register to mitigate this risk.

The provider had a business continuity plan. The plan did not provide sufficient assurance that services could be maintained safely in the event of a disruption. The policy contained inconsistent review arrangements, with the version control section stating it should be reviewed every 2 years, while the body of the document stated it should be reviewed annually. This reduced assurance that the policy was subject to effective oversight and regular review.

The plan identified a range of potential incidents, including adverse weather and power failures. Although staff shortages were recognised as a potential risk, the plan did not set out any actions to be taken in response. At the time of our assessment, the registered manager was the only sonographer employed by the service, but there were no documented contingency plan to support service continuity if key staff were unavailable. The plan also did not include arrangements for managing equipment failure, such as a scanner breakdown.

The key contact information for clients, staff, suppliers and local authorities, had not been completed. As a result, staff may not have access to essential contact details that may be needed during a business continuity incident.

The plan did not clearly define escalation processes, decision-making arrangements, roles, responsibilities in the event of a disruption. This meant it was unclear how staff would respond, who they would contact, or how decisions would be made to maintain the safe operation of the service during a business continuity event.

The policy also contained references to a mobile screening van and to printed prescriptions and blank prescription forms, which were not relevant to the services provided. This indicated the policy had not been appropriately tailored to the provider's activities or reviewed to reflect the specific risks faced by the service.

Governance arrangements were not sufficiently robust to ensure incidents and risks were routinely reviewed and effectively monitored. Incidents and risks were not included as standard agenda items and were only discussed in the April 2026 meeting minutes we reviewed. This limited assurance that learning from incidents and oversight of risks were consistently embedded within the provider's governance processes.

Where incidents were discussed, the minutes contained a summary of the incident and identified actions to be completed. Actions were not assigned to a named individual and no target completion dates were recorded. This limited accountability and reduced the provider’s ability to monitor whether actions had been implemented in a timely manner.

The minutes recorded that risks had been reviewed and that no escalation was required. There was insufficient detail regarding the discussions held, the rationale for decisions made, or arrangements for ongoing monitoring.

Although the roles of attendees were documented, individual names were not recorded within the minutes. This reduced the audit trail of attendance and made it more difficult to demonstrate who had participated in governance discussions and decision-making.

Several of the provider’s policies and procedures were not tailored to the service being delivered. We found that some policies were incomplete, contained references to equipment or services that were not relevant to the provider’s regulated activities, or included information relating to a different organisation. This indicated that policies and procedures had not been adequately reviewed or adapted to reflect the provider’s specific service. This meant the provider could not be assured that policies and procedures accurately reflected current practice or provided staff with clear, relevant and service-specific guidance. This increased the risk of inconsistencies in staff understanding and implementation of key processes and procedures.

The provider had an information governance policy, which had not been sufficiently tailored to the service. The policy stated that all non-NHS organisations should have a designated Data Protection Lead. While the policy stated that the CQC Registered Manager acted as the Data Protection Lead, it did not identify the individual by name or provide contact details, limiting clarity regarding accountability for data protection matters within the service. In addition, the policy referred to an Information Management and Technology Lead, although it was unclear whether this role existed within the organisation. The policy identified information governance risks, including the management of computerised systems and the loss, corruption or unauthorised disclosure of data. However, these risks were not reflected on the service’s risk register. This meant the provider could not be assured that information governance responsibilities were clearly defined or that identified risks were being formally monitored and managed.

However, the provider held monthly clinical governance meetings. We reviewed meeting minutes from February to April 2026. Meetings followed a standard agenda which included complaints and patient feedback, equipment servicing and staff appraisals.

The registered manager shared information with staff through a range of communication methods, including email correspondence, a staff messaging platform and team meetings. We reviewed minutes from a team meeting held in February 2026 and noted discussions relating to booking arrangements and administrative tasks.

The provider had up-to-date employers' liability insurance in place. This provided assurance that appropriate cover was available for employees and demonstrated that systems were in place to meet legal and regulatory obligations.

The provider had a documented risk assessment review schedule which set out key areas of clinical, operational, health and safety, and regulatory risk that required periodic review. The schedule identified review frequencies, responsible staff members, and the evidence expected to support each review. This provided a framework for monitoring risks across the service.

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 provider understood their duty to collaborate and work in partnership with the services that referred people for diagnostic investigations. The provider maintained effective working relationships with referring clinicians and healthcare professionals. Ultrasound reports were shared promptly with referrers to support continuity of care and ensure people could access any follow-up investigations or treatment required.

Due to the nature of the service, opportunities for partnership working were limited. However, the registered manager was actively exploring opportunities to develop additional services and strengthen relationships with other healthcare providers.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff were encouraged to suggest new ways of working to improve the service. The registered manager was committed to recruiting sonographers who shared the values of the organisation and supported a culture focused on continual improvement.

Staff demonstrated a commitment to delivering high-quality care that placed patients’ experiences at the centre of service delivery. They worked to identify and respond to the needs of people using the service and implemented practical improvements where gaps or additional support needs were identified.

For example, staff had developed information and support packs for individuals and families who received unexpected or distressing pregnancy scan findings. This helped ensure people had access to relevant information and sources of support during a difficult time.

The service had also responded to demand for additional diagnostic services and had recently introduced phlebotomy to support people's diagnostic pathways. In addition, the service offered a self-referral pathway through a secure messaging platform, enabling people to contact the service directly and receive prompt responses. This supported timely access to care and improved convenience for people using the service.

The provider demonstrated a focus on innovation and improving the patient experience. Initiatives introduced included a same-day appointment system for urgent scans, digital reporting processes to provide patients with timely results, and the use of a dedicated messaging platform to support communication, bookings and follow-up enquiries.

The registered manager continued to explore opportunities to develop the service further, including the potential introduction of additional healthcare services in response to local need.