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 the last inspection we rated this key question requires improvement. At this follow up assessment, the rating has changed to good.
This meant that 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.

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.
At the last assessment there were concerns that incidents were under reported and staff were not aware of how to report them. Staff did not meet to discuss incidents, and learning was not shared.
At this assessment the service showed improvements, we saw an increase in the number of incidents being reported by staff. Between August 2025 and April 2026, we saw that 9 incidents had been reported. All incidents had been fully investigated with actions and learning documented. Incidents were risk rated. The service had an Incident Management, Learning and Preventative practice guidance document, incident reporting policy and a duty of candour policy. Staff were supported to report incidents and had regular staff meetings where incidents were discussed, and learning was shared.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.
At the last assessment it was identified that staff were not trained to the appropriate level for the safeguarding of children. The service did not have a safeguarding lead trained to level 4, and staff had not undertaken chaperone training in line with the services' own policy. The services safeguarding policy was not applicable to the service.
At this assessment the service showed improvements. All clinical staff had been trained to level 3 safeguarding for both adults and children. Admin staff had been trained to level 2. The registered manager, who was also the safeguarding lead, had completed safeguarding training to level 4. This was in accordance with the intercollegiate safeguarding documents for adults and for children and young people. The safeguarding training included training in Female Genital Mutilation (FGM) and modern slavery.
Staff had completed chaperone training, in line with the services policy. People were asked at the prebooking stage if they would require a chaperone so that arrangements could be made for either two sonographers to be available or a family member or friend to be present.
The service safeguarding policy had been reviewed. It was in date, version controlled, and in keeping with the service provided. Safeguarding pathways and procedures were displayed with contact details of who to refer to.
Safeguarding was discussed at staff meetings.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
At the last assessment, the service did not undertake regular quality service checks on ultrasound equipment in line with national guidance. There were no effective processes in place for the management of Controlled Substances Hazardous to Health (COSHH).
There were not any audits in place to assess and monitor the environment, equipment, or consumables.
The service did not have effective arrangements in place to monitor fire safety.
Not all equipment had been Portable Appliance Tested (PAT), and there was not a faulty equipment log for managers to monitor and respond to faults.
At this assessment we observed improvements, all equipment had been serviced, PAT tested and monitored as per national guidance, with date labels attached. The service now had a faulty equipment log to assist with the monitoring and response to faulty equipment.
The COSHH cupboard was locked with keys safely locked away. Chemical information sheets were available for all chemicals held in the COSHH cupboard. All consumables were in date with a daily check list completed for stock levels.
Improvements had been seen with regard to fire safety. There was a fire safety log that documented that the annual fire safety check had been completed in October 2025. A fire risk assessment and fire drills had been completed. A fire escape plan and actions were displayed with fire exit lights above all doors. A “what three words” location was displayed to aid emergency services to find the location. “What three words” is a global location system to allow for precision location findings within 3 metres.[

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 last assessment staff competency assessments were not being completed in line with the services own Ultrasound Policy and Procedure. Managers did not provide formal supervision. Performance concerns were not always managed, documented, and actions recorded.
Staff had not completed training to support people with learning disabilities and autism. Staff meetings were not held to share information and learning.
Recruitment procedures were not always operated effectively. Recruitment documentation was stored in multiple locations both electronically and on paper meaning that we were not assured that recruitment processes were complete and verified staff suitability for their role and compliant with safe recruitment practices.
At this assessment , we found that the service had made improvements. The registered manager implemented quality control measures to review ultrasound images daily. In addition to this, each month the registered manager reviewed 3 scans from each sonographer in its entirety to check for quality of the image and the report content of the image. The registered manager was also a sonographer, their scans were reviewed by their peers. This was in line with the current professional guidance (Society of radiographers and British Ultrasound Society 2023). Any competency concerns were raised and discussed with the sonographer and supervision documented.
All staff had completed training to support people with learning disabilities and autism. Staff training was monitored and audited every month to ensure staff compliance and competence. Each member of staff had an electronic training record containing completed training and competency certificates, together with any additional Continuing Professional Development (CPD)
Staff meetings were now held bi-monthly. All staff meetings had an agenda and were minuted. Staff received copies of the minutes which they signed a receipt electronically. Complaints, IPC, safeguarding, and incidents were discussed and learning shared.
Recruitment processes were effective. All documentation was now kept electronically with only the Registered Manager and the Nominated Individual for the service having access to the files. We reviewed 3 staff files and found them all to have Disclosure and Barring Service (DBS) checks, references, identification, completed application form, induction to the service documentation and certificates of competencies and qualifications.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

At the last inspection there were inconsistencies found in the completion of cleaning records and schedules.
Fabric seating was present in both the waiting and scanning area which were not Infection Protection Control (IPC) compliant. The flooring in clinical areas did not comply with national guidance.
Staff were observed to not always be bare below the elbows. Refillable ultrasound bottles were being used that were not compliant with a 2021 national patient safety alert.
At the follow up assessment, we found cleaning schedules to be fully completed with audits in place to monitor daily cleaning of all areas. “I am clean stickers” were still not in use, however we observed staff cleaning equipment in the clinical area after patient use. This observation together with completion and audits of cleaning schedules indicated that improvements had been made in this area and met expected standards. Post assessment we were told that the service also uses laminated signage to inform staff that equipment had been cleaned, sanitised and was safe to use. However, we were not provided with evidence of this.
The fabric seating had now been removed from both the waiting and scanning areas and replaced with seating that could be appropriately cleaned. The flooring in the scanning area was in line with national guidance and could now facilitate effective cleaning. The waiting area was carpeted; however people were encouraged to use shoe coverings, that were provided by the service, on entry to the waiting area.
Staff were observed to be bare below the elbows. The service no longer used refillable gel bottles.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.