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


Inspection carried out on 23, 24, 26 April 2019

During a routine inspection

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