East Anglia Ultrasound Services

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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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score: 2

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 2. The evidence showed some shortfalls. The service did not have a clear shared strategy which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The service did not have a documented strategy in place, resulting in an absence of clear strategic direction. This limited leaders’ ability to effectively monitor progress, assess performance, and respond to emerging challenges. This posed a risk to the service’s ongoing development and continuous improvement.

Leaders undertook an annual review of the service, where they assessed financial and performance data, workforce and business developments, and data on complaints and patient feedback. While the review resulted in a set of recommendations for the year ahead, these were vague and lacked measurable outcomes. For example, suggestions such as “adapt to changes and work together for the better” and “carry on the established good working relationship” were too vague to drive meaningful improvement.

Staff were unable to clearly articulate the service’s vision, strategic goals, or their role in achieving them. This indicated a lack of shared direction across the team, which limited their ability to work towards common objectives.

Despite this, staff and leaders demonstrated a positive, compassionate, and listening culture that promoted trust and mutual understanding with the people using the service. During our assessment we saw that staff worked in line with the service’s values. Staff were committed to providing a high-quality service to all patients who used it.

Quality Statement Score: 2

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 2. The evidence showed some shortfalls. Leadership capacity was limited and this had impacted on the oversight of the service. Leaders could not always demonstrate that they had appropriate knowledge of applicable legislation and regulations.

The service was led by the registered manager, who was an experienced sonographer of over 30 years. The registered manager had led the service for over 10 years and they were therefore experienced in their role. The registered manager displayed an understanding of the context in which staff delivered care.

Leadership capacity was limited due to vacancies in key roles. The registered manager regularly worked operationally and had previously been supported by a practice manager. However, this role had been vacant since summer 2024, impacting the registered manager’s ability to focus on service management and governance oversight.

The registered manager was responsive to the concerns raised during our assessment and took swift action to address them. However, leaders had not identified the concerns prior to our assessment. This demonstrated a reactive rather than a proactive approach to leadership.

Leaders were not always able to demonstrate sufficient knowledge of applicable legislation and regulatory requirements. For example, they had not ensured that nationally recognised guidance relating to staff training, quality checks of ultrasound equipment, and the safe use of ultrasound gel had been implemented within the service.

Despite the gaps, staff spoke positively about the service’s leadership, describing leaders as visible and supportive.

Quality Statement Score: 2

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 2. The evidence showed some shortfalls. The service did not always actively promote staff empowerment to drive improvement.

Leaders did not always actively promote staff empowerment as a means of driving improvement. During our assessment, they were unable to provide evidence that they had gathered staff feedback or had sought input from staff.

Similarly, patients and carers were not actively involved in decisions about changes to the service. This may have limited opportunities to ensure that service developments were responsive to their needs and experiences.

Whilst the provider’s Freedom to Speak Up Policy stated that staff could raise concerns anonymously, no practical systems were in place to support this. As a result, some staff may have felt discouraged from speaking up, particularly if they feared retaliation or felt vulnerable. Following our on-site visit, leaders stated that they had introduced a QR code, which staff could scan to provide anonymous feedback.

Managers and staff had access to feedback from patients and carers. Managers told us that they used this to make improvements. However, there was not always documented evidence to show what actions had been taken in response to concerns raised through patient feedback. Following our on-site visit, leaders introduced a document where they recorded the actions that they had taken in response to feedback from patients and carers.

Leaders had introduced some processes to enable staff to raise concerns internally. The service had a Freedom to Speak Up Guardian and an accompanying policy, which provided clear guidance for staff about how they could raise concerns within the organisation and externally. The policy also directed staff to relevant support organisations.

Staff and leaders demonstrated openness, honesty and transparency. Staff reported feeling confident that any concerns they raised would be taken seriously and responded to appropriately, and they felt comfortable speaking up. However, none of the staff spoken with as part of our assessment had formally raised any concerns internally. Leaders were able to describe the actions they had taken to review and respond to concerns that had previously been raised with them.

When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. This was confirmed through a review of complaints and incident investigations during our assessment.

Quality Statement Score: 2

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 2. The evidence showed some shortfalls. The service did not continually review and improve the culture of the organisation in the context of equality, diversity and inclusion.

The provider did not undertake formal equality monitoring of staff to ensure it was diverse and reflective of the patient population. However, the service employed a multi-national, multi-lingual team, and managers actively recruited internationally.

Leaders were unable to provide documented evidence of any work undertaken to assess or enhance the organisational culture in relation to equality, diversity and inclusion. This may have led to missed opportunities for improvement in these areas.

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

Leaders had not yet conducted staff surveys to actively engage employees, particularly those with protected characteristics or who may feel excluded or marginalised. Additionally, there were no equality and diversity champions within the service. However, the staff team was small, and staff felt able to raise concerns informally. All staff we spoke with during our assessment felt they were treated equitably.

Leaders had put some measures in place to support equality and diversity. Staff completed relevant training, and the service had an equality and diversity policy in place. Discussions regarding equality and diversity had been built into the appraisal process. Flexible working was available to support staff with personal needs, such as caring responsibilities or health conditions.

Quality Statement Score: 1

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 1. The evidence showed significant shortfalls. Leaders did not operate effective governance processes. Systems were not in place to manage performance effectively. Managers did not always identify and escalate relevant risks and issues, and identify actions to reduce their impact.

The service lacked effective systems and processes to assess, monitor and improve the quality and safety of the service. For example, there was no evidence of audits being carried out to assess staff compliance with internal policies or national guidance, limiting the ability to identify and address areas requiring improvement.

The service did not monitor all essential performance data necessary to maintain the quality of the service. For example, the service did not monitor appointment waiting times, time taken to receive results for non-invasive prenatal testing (NIPT) and other blood tests, or length of time taken to contact patients’ GPs or other healthcare providers. There were no key performance indicators in place to evaluate service performance or to identify when corrective action was required. This meant there was a risk that areas of poor performance may not be identified or addressed in a timely manner. Following our on-site visit, leaders carried out an NIPT audit, which included a review of time taken to receive results. Leaders stated that they closely monitored the blood test process through a portal, which was accessible 24 hours a day.

The service did not have effective systems in place for identifying, recording and managing risks associated with the service, and the service did not have a risk register. Although leaders had completed a health and safety risk assessment in 2025, it did not cover all risks relevant to the service. For example, leaders identified key risks such as abuse towards staff, the potential for misdiagnosis, and safeguarding concerns, but these were not formally documented. As a result, there was no evidence to show that appropriate actions had been taken to mitigate these risks or that they were subject to regular review and update.

Leaders had not held any meetings to review the quality and safety of the service in the year prior to our inspection. This may have resulted in missed opportunities to identify risks, address concerns, and drive continuous improvement.

There were no formal staff meetings in place, which could have provided a valuable forum for sharing, learning, communicating updates and enabling staff to raise concerns. Instead, the service relied on a communication book for staff to share updates with one another.

The service did not have effective systems in place for maintaining ongoing oversight of key operational areas. For example, leaders were unable to provide assurance that staff maintained the necessary competencies or had up-to-date skills relevant to the scans they performed and the equipment they used.

During our on-site visit, leaders were unable to confirm that all required recruitment documentation was in place for staff. This lack of oversight posed a potential risk to both the safety and quality of care delivered.

The service did not have a formalised process for reviewing and approving policies. Leaders were unable to provide the service’s standard operating procedure for policy review and approval when this was requested during our assessment. Policies were developed and reviewed by an external organisation, but it was unclear whether leaders subsequently reviewed them to ensure alignment with the actual practices in place at East Anglia Ultrasound Services. As a result, many policies included references which did not reflect the service provided. For example, policies described audits, meetings, competency assessments and quality assurance programmes which were not in place.

The service had a business continuity plan in place, but it had not been fully completed. For example, it lacked contact details for external organisations.

Leaders were unable to provide evidence of workforce planning when requested during our assessment. The absence of such planning meant the service had not reviewed whether it had the right number of staff with the appropriate skills to meet current and future demands. This posed a risk to service continuity and the quality of care.

Quality Statement Score: 3

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

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.

Partner organisations described staff and leaders as open and transparent. They also highlighted the collaborative approach taken by staff to support the delivery of high-quality care. Staff at East Anglia Ultrasound Services were described by partner organisations as “experienced, thorough and attentive”.

Staff communicated with GPs or other healthcare professionals when required to share reports and images, with patients’ consent. Leaders had worked to build relationships with local GP practices and early pregnancy units (EPU). Patients described how staff worked in partnership with external providers to support time-sensitive fertility treatment by offering appointments at very short notice. The service did not yet have referral links or contacts for fetal medicine units (FMU).

The service had a contractual agreement with a pathology service for NIPT and other blood tests, which included arrangements for sample tracking and receipt of results. Leaders had a designated point of contact at the pathology service, to raise any issues or concerns. However, they did not hold regular meetings with the provider or formally monitor performance data. This lack of oversight meant leaders could not be assured of the quality, timeliness, or reliability of the pathology service.

Staff and leaders had not yet engaged with partners to share learning which would result in continuous improvements to the service. However, partner organisations said that they could always contact staff for advice or clarification regarding findings.

Quality Statement Score: 2

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Concerns identified during our last assessment had not been fully addressed. For example, we remained concerned regarding the service’s governance and risk management processes. This suggested that staff and leaders did not always have a good understanding of how to make improvement happen.

Leaders did not carry out a programme of repeated audit to identify learning and areas for improvement. This indicated the service was not always focused on continuous learning and improvement. Leaders stated that staffing levels had impacted on their ability to carry out audits. Following the recruitment of a new member of staff in August 2025, the service had begun to implement an audit programme.

The service did not have an effective system in place to actively seek and respond to staff feedback. Leaders were unable to provide evidence of gathering staff feedback, when this was requested as part of our assessment. Staff interviewed throughout the assessment felt that leaders were open to feedback but could not provide specific examples of times they had been asked for their views or had the opportunity to contribute feedback. This lack of engagement limited the service’s ability to identify concerns and drive service improvement.

Staff and leaders had not ensured that people using the service, along with their families and carers were involved in the development and evaluation of improvement and innovation initiatives. When changes were made in response to feedback or complaints, people were not given the opportunity to be involved in shaping the solutions and measuring the impact. This limited the service’s ability to ensure that improvements were genuinely aligned with patient needs and experiences.

The service had processes in place to support learning when things went wrong. This was confirmed through our review of complaints and incidents during our assessment.

Leaders shared examples of good practice with staff and encouraged participation in external learning opportunities, such as conferences.

Staff appraisals included a focus on service improvement, with metrics assessing whether staff identified and evaluated areas for potential service improvement.