East Anglia Ultrasound Services

On this page

• 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 remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the regulations for safeguarding and safe care and treatment.

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.

Quality Statement Score: 2

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive safety culture. Learning from incidents and complaints was not always shared with staff.

Incident reporting levels within the service were low. This raised concerns that the service could be under-reporting incidents and did not have a proactive safety culture. Leaders stated that there was a low rate of incidents and complaints because staff closely monitored incidents and listened to patient’s feedback and suggestions. In the 12 months prior to our assessment, only one incident had been reported. This incident was not identified through routine staff monitoring or internal safety checks but was instead brought to the service’s attention through a complaint. Apart from the registered manager, none of the staff we spoke with during our assessment had experience of reporting an incident at the service. While staff were able to identify the types of concerns that should be reported as incidents, not all were familiar with the procedure for reporting them. Instead, most staff said they would seek advice from the registered manager when needing to report an incident.

The registered manager was responsible for conducting investigations into all incidents but had not completed any incident investigation training. This may affect the overall effectiveness and consistency of incident investigations. However, the registered manager told us they felt competent to undertake incident investigations based on their previous working experience. The incident reviewed as part of our assessment had been thoroughly investigated and actions had been taken in response to the learning identified.

Staff did not meet to discuss learning from incidents or complaints. They could not recall receiving this information in other formats, such as by email. As a result, opportunities to improve practice and prevent similar issues from occurring may have been missed. However, staff did have access to a folder with information on incidents and complaints.

The service’s accident and incident reporting policy and procedure did not always provide clear guidance for staff. For example, the policy did not provide guidance about how incidents should be investigated and how the level of harm should be graded when an incident happened. This may have led to inconsistent reporting and investigation practices.

Complaints had been thoroughly investigated and actions taken in response to learning identified. For example, changes were made to the images and measurements recorded for abdominal scans.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

Staff and people using the service expressed confidence that concerns could be raised without fear of blame or negative treatment, and that they would be received with compassion and understanding.

Quality Statement Score: 3

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

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.

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 or their carer before each appointment. The questionnaire included questions about medical conditions, medications, allergies, previous hospital stays, scans, and blood tests. We reviewed 5 patient records during our assessment and found that the questionnaires had been fully completed before each appointment.

Staff shared key information to keep patients safe when handing over their care to others. All patients received electronic access to images from their scan and the report to share with other health care professionals. Staff could also share scans and reports with health care professionals directly, with explicit patient consent to do so. If necessary, staff contacted relevant health care professionals by telephone to escalate concerns.

Quality Statement Score: 2

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 2. The evidence showed some shortfalls. Staff were not always trained to an appropriate level for their role in how to recognise and report abuse.

Leaders had not ensured that all staff were trained to an appropriate level in safeguarding children. For example, a sonographer performing paediatric scans was not trained to level 3 safeguarding children, and the 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). As a result, there was a risk that staff may not be equipped to recognise or respond appropriately to safeguarding concerns. Following our assessment, leaders told us they would ensure staff completed the appropriate level of training in safeguarding children.

Staff knew who to inform if they had safeguarding concerns. However, some staff lacked awareness of how to respond to specific safeguarding issues, such as modern slavery and female genital mutilation. Staff told us they had rarely, if ever, encountered these concerns at East Anglia Ultrasound Services.

The service had policies for safeguarding both adults and children & young people. However, the safeguarding policies had been created by an external organisation and were designed for use in primary care settings, such as GP practices. As a result, some of the policy contents were not directly applicable to the service. For example, the policies referred to national guidance specific to general practice, including Safeguarding Standards for General Practice. In addition, the policies did not include contact details for the local authority. However, this information was displayed in a range of locations within the clinic. The policies did not always include an explanation of or guidance on specific safeguarding issues such as female genital mutilation or forced marriage. However, the policies did include hyperlinks to external guidance.

Staff had access to a safeguarding lead for additional support and guidance. The safeguarding lead told us they would contact the local authority directly if they needed further advice.

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

Staff had not undertaken chaperone training. This was not in line with the provider’s own Chaperone Policy. This was also not in line with the Society of Radiographers and British Medical Ultrasound Society’s ‘Guidelines for Professional Ultrasound Practice’ (2023), which states “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. Following our assessment, the registered manager stated that staff had completed chaperone training.

Quality Statement Score: 3

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

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.

Patient risk was assessed prior to each appointment through the completion of a medical questionnaire.

Sonographers checked 3 points of patient identification to ensure the right person received the right ultrasound investigation at the right time.

There were clear processes in place to respond to any unexpected or significant findings during the scan. This included advising patients to attend Accident and Emergency for urgent concerns, or where consent was given, contacting the patient’s GP, midwife or local hospital to ensure appropriate follow up care.

Processes were in place to ensure staff could responded promptly to any sudden deterioration in a patient’s health. The service had a first aid kit available. All staff working for the service had completed basic life support (BLS) training. There was always a member of staff on duty who had undertaken paediatric and newborn resuscitation training. This meant that staff were trained to respond to any sudden deterioration in the health of a child or young person using the service. In the event of a medical emergency, staff contacted emergency services by dialling 999.

The service did not have a referral pathway for women experiencing acute anxiety or mental health crises during pregnancy. This meant there was no set process for staff to follow to ensure women were provided with the right support when concerns were raised about their mental health. However, staff told us they would contact the patient’s midwife or GP and provided examples of having previously done so for women with mental health concerns.

The service did not have formalised inclusion and exclusion criteria to ensure staff only accepted patients whose needs could be met by the service. However, staff told us that appointment requests would go through a justification process by a sonographer, where the patient’s medical questionnaire would be reviewed to ensure that the service would be able to meet the patient’s needs.

Quality Statement Score: 2

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 2. 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 supported the delivery of safe care.

Leaders had not implemented a process for regular quality and safety checks of ultrasound equipment. This was not in line with national guidance (Society of Radiographers and British Medical Ultrasound Society 2023). The absence of such checks increased the risk of delays in identifying equipment-related safety and quality concerns. We fed this back to the service and leaders put in place regular quality and safety checks following our on-site visit.

We identified expired consumables in both scanning rooms and in a cupboard within the reception area. Leaders confirmed that these items were no longer in use and disposed of them during our on-site visit.

The service did not always have effective processes for the management of Control of Substances Hazardous to Health (COSHH). Hazardous substances were not always securely stored in the designated COSHH cupboard. We observed cleaning supplies being stored in the female toilets and drain cleaner in the scanning room cupboard. There were no warning signs in place on the COSHH cupboard to alert staff to the presence of hazardous substances. The COSHH cupboard was lockable. However, we observed that keys had been left in the locks. We fed this back and leaders addressed these concerns following our on-site visit.

Managers had not ensured all electrical equipment had been safety tested in the 12 months prior to our inspection to ensure it was safe to use. Equipment had last undergone Portable Appliance Testing (PAT) in December 2023. The provider’s records stated that PAT testing should have been undertaken again in December 2024. Testing was therefore over 7 months overdue at the time of our assessment. The ultrasound equipment and examination bench in the service’s second scanning room had not been serviced for over 2 years prior to our assessment. Leaders told us this was because the equipment was no longer in use. However, they subsequently confirmed that the room and the examination couch within it was occasionally used to take bloods. There was no sign on the equipment to inform staff that the equipment was not in use. The equipment should have been serviced and maintained whilst it remained within the service. Following our feedback and on-site visit, leaders began to take action to remove the equipment from the service. Leaders stated that a notice had been attached to the machine following our assessment to inform staff that the equipment was not in use.

The service did not always have effective arrangements in place for fire safety. Staff had not carried out a fire drill to practice evacuation procedures since 2023, despite legal requirements to undertake fire drills annually. Leaders were unable to provide a comprehensive fire risk assessment when this was requested during our assessment. Leaders informed us that an external fire risk assessment was scheduled to take place shortly after our assessment. However, fire extinguishers had been regularly serviced and fire alarms were tested on a weekly basis. There was also evidence that actions had been taken to improve fire safety in response to previous fire risk assessments.

Staff used a daily stock monitoring spreadsheet to track inventory levels and identify when new supplies needed to be ordered. There were some inconsistencies in the completion of the spreadsheet prior to June 2025, which could have impacted staff’s ability to monitor stock levels. However, compliance improved after June 2025.

There were no audits in place to assess and monitor the condition of the environment or equipment, including consumables. In addition, there was no documented evidence that the completion of daily stock and equipment checklists were monitored. As a result, the concerns we found during our inspection had not been identified or resolved.

The service did not have an equipment fault log to enable managers to monitor any faults identified and actions taken in response. We fed this back and this concern was addressed by the registered manager following our on-site visit.

First aid equipment was readily available and regularly checked.

Staff disposed of and stored clinical waste safely. Staff ensured sharps bins were correctly assembled and below the fill line. Staff used the correct bins to dispose of clinical waste and domestic waste. Clinical waste was collected by an external contractor.

Quality Statement Score: 2

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 2. The evidence showed some shortfalls. Staff did not complete competency assessments and managers did not provide staff with formal supervision. Recruitment procedures were not always operating effectively.

Staff had not completed competency assessments, which was not in line with the service’s own Ultrasound Policy and Procedure. This policy stated that “competence in carrying out ultrasound scans will be reviewed annually with a competency assessment.” Leaders confirmed that sonographers were not required to provide evidence demonstrating that they maintained their competence or possessed up-to-date skills for the types of scans they were performing or the equipment they were using. When we requested evidence of any paediatric sonography training undertaken by sonographers, this information was not made available to us. The absence of formal competency checks meant that leaders did not provide assurance that staff were appropriately skilled to carry out specialised scans and operate equipment safely. Following our assessment, the registered manager introduced an audit which reviewed sonographers’ report quality and image quality.

Managers did not provide staff with formal supervision. The registered manager told us that, due to the small size of the team, support was provided through informal discussions instead. While informal support could be beneficial, the absence of structured supervision may limit opportunities for staff to reflect on their practice, receive consistent feedback, and identify learning needs, potentially impacting the quality of care and staff wellbeing.

There were no staff meetings in place. Staff meetings would have provided an opportunity for leaders to share learning and other relevant information, and for staff to discuss and raise any concerns. The service had a communication book to allow staff to share updates with each other.

Most staff (5 out of 6) had not completed training on how to support patients with learning disabilities and autism. Since 1 July 2022, all registered health and social care providers have been required by the Care Quality Commission to ensure staff receive training in learning disability and autism, including how to interact appropriately with autistic people and people who had a learning disability. Following our assessment, leaders stated that all staff had completed training on supporting patients with learning disabilities and autism.

Recruitment procedures were not always operated effectively. During our on-site visit, we found that a range of information was missing from the 4 recruitment files that we reviewed. This included evidence of qualifications for one sonographer, induction documentation for 3 members of staff, a Disclosure and Barring Service (DBS) check for one member of staff, and evidence of conduct in previous employment for one member of staff. Two members of staff only had 1 reference on file. The registered manager could not locate the information during our on-site visit and told us the issue had arisen because recruitment documentation was stored in multiple locations, with both electronic and paper records. Following our site visit, the registered manager was able to locate some, but not all, of the missing information. This meant that the service did not have robust systems in place to ensure recruitment records were complete, accessible, and consistently maintained, potentially compromising the ability to verify staff suitability and compliance with safer recruitment practices.

The registered manager provided examples of times that they had dealt with poor staff performance. However, the registered manager did not document the action they had taken. This meant we were not assured that performance concerns were managed consistently and in line with organisational procedures.

The service had enough staff to keep patients safe. The service employed 4 sonographers, 1 student sonographer and 1 clinic assistant. The clinic assistant staffed the reception desk, supported the sonographer as required and acted as a chaperone.

Managers calculated and reviewed the number and grade of staff needed. Managers scheduled at least 1 sonographer and 1 clinic assistant for each clinic. The clinic would be cancelled if managers were not able to meet the planned staffing numbers. The service did not use agency and bank staff.

At the time of our assessment, the service had 1 vacancy, for a practice manager. This post had remained unfilled for approximately a year. The registered manager explained that efforts to recruit had been unsuccessful due to challenges in finding a candidate with the appropriate skills and experience.

The registered manager told us that 2 sonographers had left the service in May and June 2025. This equated to a turnover rate of 33.3%.

The service had low sickness rates. The registered manager told us there had been no sickness in the 12 months prior to our assessment.

All staff had received an appraisal within the 12 months prior to our assessment.

Most staff were up to date with their mandatory training. The registered manager monitored compliance using individual staff monitoring records, which included the expiry dates of each training course. However, there was no set target for overall compliance rates.

Quality Statement Score: 2

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

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.

Cleaning of the premises and equipment was carried out by sonographers and clinic assistants.

Cleaning schedules were in place. However, we identified inconsistencies in the completion of cleaning records. For instance, checklists indicated that toys were only cleaned once per month between April and June 2025, the floor had not been cleaned for 13 days in July, and the toilets had not been cleaned for 14 days in June 2025. We were therefore not assured that all areas were being cleaned in line with expected standards.

Staff did not label equipment to show when it was last cleaned. For example, through the use of ‘I am clean’ stickers. The use of 'I am clean' stickers would have provided a clear visual indication that equipment has been cleaned and was ready for safe use, which would help to prevent cross-contamination and support infection control practices.

Clinical areas were generally visibly clean and furnished with appropriate, well-maintained items. However, some dust was observed in the scanning rooms. The registered manager stated that this area was near to a window which was open for ventilation and this impacted on staff’s ability to keep the area dust free.

Fabric seating was present in both the waiting area and the scanning room. This type of seating did not comply with infection prevention and control standards. Staff told us that the seating was steam cleaned 3 times a year; however, there was no documentation available to verify this. Following our assessment, the registered manager stated that cleaning checklists had been updated to include steam cleaning of fabric seating.

The flooring in clinical areas did not comply with national guidance, specifically the Department of Health’s Health Building Note 00-10, as there was no continuous coved junction between the floor and the wall, to facilitate effective cleaning. Following our assessment, the registered manager begun liaising with the building’s landlord to get agreement for the flooring in clinical areas to be replaced. The registered manager stated that adhesive sealant had been applied along the skirting boards as an interim measure.

Staff did not always adhere to ‘bare below the elbows’ principles. For instance, one member of staff was wearing a watch and another was wearing a long sleeve top. This increased the risk of cross-contamination. Following our site visit, leaders said that they would remind staff about ‘bare below the elbows’ principles.

There were no audits in place to monitor staff compliance with infection prevention and control principles. In addition, there was no documented evidence that the completion of daily cleaning checklists was monitored. As a result, the infection prevention and control concerns identified during our inspection had not been previously recognised or addressed by the service.

The service was using refillable gel bottles, which was not compliant with the 2021 National Patient Safety Alert ‘The safe use of ultrasound gel to reduce infection risk’. This practice increased the risk of cross-contamination and infection. Following our assessment, leaders stated that the service was no longer using refillable gel bottles.

Staff cleaned and decontaminated ultrasound probes in line with the service’s policy and national guidance.

Personal protective equipment was readily available for staff to use. Staff were observed using personal protective equipment appropriately. Staff had access to appropriate hand washing facilities and sanitising hand gel was available.

Quality Statement Score: 3

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

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

The service did not store or administer any medicines or controlled drugs.