Lakeside Medical Diagnostics

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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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

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 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff demonstrated awareness of incident reporting procedures. Staff were able to describe the incident reporting process, however, records showed that the service had no clinical or non‑clinical incidents in the last 12 months.

The evidence states that there are systems in place to ensure any future incidents would be managed, investigated and documented appropriately . Therefore, we were not assured that the provider had effective systems in place to identify risks, learn from events, or prevent recurrence.

However, there was evidence that patient feedback led to changes. For example, a patient had reported that the signage was unclear, and the service responded by improving the signage and giving clearer directions when booking appointments over the phone.

The service provided mandatory training in key skills to all staff. The managers monitored mandatory training and alerted staff when they needed to complete updates. All mandatory training was up to date.

The provider carried out 13 imaging quality audits in the last 12 months on 13 different patients records. Results showed 100% compliance.

We scored the service as 3. The evidence showed a good standard. 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’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.

The service had a Standard Operating Procedure (SOP) ensuring that the right person, underwent the right scan at the right time.

We reviewed a sample of 7 imaging referral forms during our assessment and staff had completed all of them with the relevant information. The forms were legible and signed. Staff confirmed that they considered patient needs during a pre-assessment phone call before their appointment, including whether the patient required any reasonable adjustments. Staff also informed patients about the next steps and provided contact details for continuity of care post imaging procedure.

Referrals were completed on paper, but diagnostic imaging details and radiological reports were transferred through an encrypted electronic system using a USB storage device and sent to the relevant clinician .

Sonographers highlighted the ultrasound form when a scan required urgent radiological reporting before sending to an external radiological reporting service.

On the day of the visit, we were told that the USB storage device was stored on top of shelves in an unlocked room. However, in a post‑inspection interview, the registered manager told us they were stored in a locked filing cabinet.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were able to describe safeguarding responsibilities and were trained in accordance with national guidance. All clinical staff had completed level 2 safeguarding training.

Staff accessed support from the safeguarding lead who had completed level 3 safeguarding training.

During our assessment, staff we interviewed demonstrated awareness of who the safeguarding lead was and explained how they would escalate any concerns. Staff also described an example of managing a safeguarding issue.

Staff received training specific for their role on how to recognise and report abuse. Staff were trained to level 2 for safeguarding adults and children.

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 so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. The service arranged interpreters and alternative communication formats when needed.

We observed staff providing an explanation of a trans-vaginal ultrasound procedure and confirmed that they understood the procedure and sought consent. Patients that we observed were satisfied with the care that they received. Staff enabled patients to give feedback on the service they received using paper and digital surveys.

Staff were able to approach the manager with ideas and suggestions, to support care and meet people’s needs.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The facility followed national guidelines in its design to keep patients safe. However, the practice did not provide a safe or compliant environment for patient care. A portable heater was positioned in the scanning room, posing a potential trip hazard. Equipment had not been PAT tested, but we were provided with immediate assurances post assessment.

Several doors had key‑coded locks, but most displayed notes stating, ‘do not lock’, which undermined the intended security measures.

The resuscitation trolley was located in the main reception area, but staff told us that it belonged to another provider in the building, so they did not complete daily or weekly checks. Although staff stated they could locate the trolley quickly and knew where the equipment was if needed, we were not assured that the absence of routine checks provided a safe or reliable emergency response.

Bottles of ultrasound gel were stored in hot water in the sink, and staff told us this was to keep the gel warm for patients, which is not in line with the providers policy. The registered manager informed us that the service previously used an electric gel warmer with temperature controls, but it broke and had not been replaced. Storing gel in hot water does not allow safe temperature regulation and poses a risk of overheating and potential harm to patients.

Not all areas of within the service were visibly clean. The waiting area had bookshelves which had clutter and visible layer of dust. It was not well maintained. Clinical staff had no space for storage of bags and coats; these were stored in the clinical room under the desk and behind the door creating a trip hazard.

However, a sample of consumables were examined and found to be in date.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of the assessment the service ensured that 100% of all sonographers had the relevant qualifications and were DBS compliant.

Clinical staff working at Lakeside Medical Diagnostics were employed part time but also worked bank shifts in a local NHS Trust and agency shifts at other providers.

The services’ mandatory training compliance was good. Staff had received all relevant mandatory training and were very satisfied with the induction process they had received. They said that they had been given the time to gain competency and were well supported to complete mandatory training annually.

Clinical staff received supervision including discussions on care management, reflection, and professional development and had regular appraisals of their performance. The registered manager completed staff supervisions.

The service had an appraisal rate of 100% at this location, exceeding the service benchmark of 95%.
Staff that we spoke to said they could approach the manager with ideas and suggestions.

Staff said that the manager was approachable, and they maintained a good relationship.

Senior staff met weekly to review patient lists, issues, complaints, capacity, staffing and service pressures. They did not share meeting summaries with administrative staff or sonographers. Staff told us differing work patterns made regular team meetings difficult, and most communication occurred via messages on personal devices. The service lacked formal assurances that important information was shared and received by staff. This reduced opportunities for in-depth discussions on shared communications.

The service rescheduled patients for sicknesses or absences.

The service had an administrative post at the time of inspection, which had been filled post assessment period.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff were bare blow elbows; however, we noted some clinical staff had nail varnish and acrylic nails which did not comply with the providers infection‑prevention policy or standards as set out by World Health Organisation.

Bottles of ultrasound gel were stored in hot water in the sink. This restricted staff access to the sink, meaning they could not wash their hands in between patient conduct. This was not in line with infection‑prevention standards. However staff wore gloves and changed them between patients.

Despite requesting hand‑washing audit records for the past 12 months, the provider submitted only a single audit: one observation of two members of staff, dated 05 January 2026. The results showed 100% compliance. We were not assured that regular audits were undertaken which compromised oversight and improvement opportunities of infection control practices.

External cleaners provided the environmental cleaning for the entire building including other providers facilities. However, not all areas of diagnostic imaging were visibly clean. For example, the waiting area had bookshelves which had clutter and visible layer of dust.

However, we observed cleaning of the ultrasound probe between patients, cleaning of the trolley, and there were in date disposable curtains in the clinical room.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The location did not order, store or use medication. A shared resuscitation trolley was available withing the building however, responsibility for the trolley rested with another provider. That provider undertook daily and weekly checks. The service did not demonstrate how it assured itself that these checks were completed and that the trolley was safe and ready to use.

No other medicines were stored at Lakeside Medical Diagnostics.