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This service was previously registered at a different address - see old profile

Inspection Summary

Overall summary & rating


Updated 4 July 2019

Peninsula Ultrasound is operated by Peninsula Ultrasound Limited, from the registered location at Threemilestone in Truro. The service also has a number of satellite clinics across Cornwall and Devon. The satellite clinics are those which operate from premises, such as GP surgeries, in areas throughout Cornwall.

The service provides ultrasound diagnostic services for adults over the age of 18. We visited the Threemilstone clinic and those in Newquay, St Austell and Kingkerswell.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 23, 24 and 26 April 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated it as Good overall.

We rated safe, effective, caring and responsive as good. We found the following areas of good practice:

  • The service had systems and practices to protect patients and protect them from harm.

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe and to provide the right care and treatment.

  • There were systems and processes to manage infection risks and staff were provided with information on the control of infection.

  • The environment and equipment used to deliver the service was fit for purpose and kept patients safe.

  • Patient medical records were maintained, up to date and stored securely. Staff had access to the relevant information they required to deliver a safe service.

  • There was an effective system for reporting incidents and staff understood their responsibilities to raise concerns, record safety incidents, concerns and near misses. Appropriate action was taken following a reported incident.

  • Care and treatment was delivered in line with national best practice guidance and legislation.

  • Staff worked well together and with external clinicians to understand and meet patient’s needs.

  • Staff assessed whether patients had the capacity to make particular decisions whenever this was necessary.

  • Patients were treated with dignity, respect and kindness during all interactions with staff. Patients were provided with information to help them understand their diagnostic test. Patients were positive about the care and treatment they received.

  • The needs of the patients were met through the organisation and delivery of the service. This included individual needs and personal preferences.

  • The service responded to and learnt from any complaints received.

  • The managers had the skills, knowledge and integrity to lead and manage the service effectively.

  • There was a clearly developed vision and set of values within the service which staff were aware of and complied with. The service was person centred, open and inclusive.

However, we also found the following issues that the service provider needs to improve:

  • Staff were not provided with full information on how to report any potential or actual safeguarding concerns.

  • Staff did not consistently comply with the infection control procedures regarding the bare below the elbows policy adopted by the service.

  • Staff appraisals were not carried out which meant there was a risk that the provider was not aware of the training needs and development requirements of the staff.

  • Not all patients were provided with full information or had not retained the information they required to prepare for their ultrasound appropriately.

  • It was not clear how the service would arrange interpretation and translation services for patients whose first language was not English.

  • There were governance frameworks to support the delivery of good quality care. However these were not fully developed to provide full assurances that the service was performing well and areas of improvement would be addressed.

  • The recruitment process was not sufficiently robust to ensure staff were suitable to work within the service.

Following this inspection, we told the provider that it must take action to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals

Inspection areas



Updated 4 July 2019

We rated safe as Good because:

  • Staff received effective mandatory training in the safety systems, process and practices. This included infection control, hand washing, coronary pulmonary resuscitation (CPR), safeguarding, equality and diversity, information governance and data protection.

  • There were systems, processes and practices to keep patients safe identified, put into place and communicated to staff.

  • However, the policy and procedure to safeguard adults from abuse did not fully reflect the contact details for external organisations who would be involved in suspected abuse.

  • The service managed the control and prevention of infection well. Where the service was responsible, staff were trained and understood their role and responsibilities for maintaining high standards of cleanliness and hygiene in the premises.

All areas we visited during our inspection were clean, tidy and hygienic in appearance. The patient survey carried out in January 2019 found that out of 140 respondents who were asked about cleanliness at the

  • clinic they attended, 124 said it was excellent, 15 very good and one good.

  • Staff were clear about their responsibilities regarding premises and equipment. They used equipment correctly to meet statutory requirements and supported people to stay safe. The design, maintenance and use of facilities and premises prevented patients from avoidable harm.

  • The sonographer and clinical assistant carried out checks prior to the patient undergoing an ultrasound. This included checks on the identity of the patient, the reason for attendance at the clinic and information regarding any allergies.

  • There were always enough competent staff on duty. Staff had the right mix of skills to make sure that practice was safe and that they could respond to unforeseen events. Staff worked flexibly to cover all planned clinics. The service did not employ any medical staff.

  • There were always enough competent staff on duty. Staff had the right mix of skills to make sure that practice was safe and that they could respond to unforeseen events. The service regularly reviewed staffing levels and adapted them to people’s changing needs. The records we reviewed during the inspection were of good quality and stored securely.

  • The service did not dispense or administer medicines.

  • There was an effective system in place for reporting incidents. Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses. When something went wrong, there was an appropriate thorough review or investigation that involved all relevant staff, partner organisations and people who used the service. Lessons were learnt and communicated widely to support improvement.

  • However, the service had not formalised a procedure to ensure staff recognised and responded to the risk of a patient becoming unwell.


Updated 4 July 2019



Updated 4 July 2019

We rated caring as Good because:

  • People were treated with dignity, respect and kindness during all interactions with staff. Their relationships with staff were positive.

  • Staff were kind, caring and welcoming.

  • The service made sure that staff had the time, information and support they need to provide care and support in a compassionate and person-centred way.

  • Staff provided support throughout the patient’s procedure, provided patients with ongoing information as to what they were doing and why and provided a brief summary at the end.

  • The service provided sufficient time for staff to develop trusting relationships with people, their families, friends and other carers.

  • Staff communicated in a way which patients understood what was happening to them. Clear instruction was provided to the patient throughout the procedure.



Updated 4 July 2019

We rated responsive as Good because:

  • Patient’s needs were met through the way services were organised and delivered.
  • The service provided was accessible and were mainly held in GP surgeries. These locations were on an established bus route and there was public car parking available.
  • People’s needs were identified, including needs on the grounds of protected equality characteristics, and their choices and preferences and how these were met. These activities were regularly reviewed and drove service development.
  • The service provided timely access to patients for their ultrasound appointment. Patients were able to choose which clinic they wished to attend. The service had not exceeded their target of 2% of patients who did not attend for their appointment in the last year.
  • The service used the learning from complaints and concerns as an opportunity for improvement. Staff could give examples of how they incorporated learning into daily practice. The service had received seven complaints in the last year, all of which had been responded to appropriately.


Requires improvement

Updated 4 July 2019

We rated well-led as Requires improvement because:

  • Leaders had the skills, knowledge, experience and integrity to manage the service. The registered manager had attended and external management course to update and develop their skills.
  • The provider had a clear vision and a set of values with quality and safety as their top priority. Staff were aware of the vision and values of the service and demonstrated the values in their work.
  • The service had a positive culture that was person-centred, open, inclusive and empowering. The managers and staff had a well-developed understanding of how they prioritised safe, high-quality, compassionate care. Staff were positive about working for the service and felt valued and listened to by their managers.
  • Electronic patient records were kept secure to prevent unauthorised access to data. Authorised staff demonstrated they could be easily accessed when required.


  • While there were governance frameworks to support the delivery of good quality care these were not fully developed to provide full assurances that the service was performing well and areas of improvement would be addressed. The recruitment process was not robust to ensuring the staff members were suitable for working within the service.
  • There were no risk assessments for individual clinics and there was no risk register for the service. This did not ensure that identified risks were mitigated against.
  • Staff were not held regularly, lacked structure and were not formally minuted. This did not ensure that the provider regularly engaged with staff and meant staff did not have a regular, formal means to raise issues or concerns with the provider.

Checks on specific services

Diagnostic imaging


Updated 4 July 2019

The service provided diagnostic and imaging services through the provision of ultrasound scanning for adults in Devon and Cornwall.

We rated this service as good because it was safe, effective, caring and responsive, although leadership requires improvement.