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, supporting learning and innovation and promoting an open fair culture.
At our last assessment we rated this key question as requires improvement. At this follow up assessment, the rating has changed to good.
This meant the service was consistently managed and well-led. Leaders and the culture promoted high-quality person centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy, and culture.
At the last assessment it was identified that 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.
At this assessment there were some improvements seen to the service. The vision and values of the service were displayed for all staff to see. The service now had a documented business strategy in place which included a growth strategy as to how the vision was going to be achieved.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.
At the last assessment it was identified that leaders did not always actively promote staff engagement as a means of driving improvement. The service was unable to provide evidence that they had gathered staff feedback or had sought input from staff.
It was not clear how the service responded to feedback received by people using the service, their family or carers and how this was used to improve the service.
The Freedom to Speak Up Policy stated that staff could raise concerns anonymously, but there were no practical systems in place to support this.
At this assessment improvements had been made. Regular bi-monthly staff meetings were now held and these meetings had an agenda and were minuted. Staff had access to a QR code to provide anonymous feedback.
People using the service were sent questionnaires following their appointments or could scan a QR code to provide feedback to the service. The service documents the feedback received to make improvements. The service was receiving regular feedback from people stating how difficult the location was to find. The service responded to this feedback by contacting google maps to make changes to the location. Changes were made to their website to include directional videos of the entrance to the service and people could be sent a direct link for the location.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability, and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

At the last assessment, it was identified that the service lacked effective systems and processes to assess, monitor and improve the quality and safety of the service.
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.

The service did not have effective systems in place for identifying, recording and managing risks associated with the service. The service did not have a risk register.

There was a lack of staff engagement. There were no formal staff meetings in place for information and learning to be shared and for staff to raise concerns.
The service did not have effective systems in place for maintaining ongoing oversight of key operational areas such as safe recruitment, staff training and clinical competencies.
The services policies did not reflect the service. Protocols were out of date and not in line with national guidance.
At this assessment the service had shown improvements in all areas identified above. Audits and quality assurance processes were being undertaken for the quality and reporting of images, IPC, staff training and competencies. Staff now electronically signed an acknowledgement that they had read policies, protocols and national guidance documentation.
The service audited and monitored key performance indicators for example appointment attendance, people returning for repeat scans, cancelled appointments by people using the service and waiting times. Waiting times from arrival to being seen averaged 5 minutes. The registered manager also monitors and audits the time the sonographer spends with the person against the quality of the image, to ensure that people are not being rushed. The service also audited and monitored blood samples for errors within the samples and collection times and results. Audit allows the service to maintain a good quality service and to identify areas for improvement.
The service no longer provided services for pregnancy related scans so did not audit for NIPT.
The service now had a risk register that was reviewed regularly and discussed at governance and staff meetings. The risk register used a scoring system to grade the risk as low, medium or high risk.
Staff and governance meetings were now being undertaken bi-monthly. These meetings had an agenda and were minuted. Complaints, incidents, safeguarding and IPC were all discussed. These meetings now gave staff a forum in which they could raise concerns and where learning could be shared.
Staff had an electronic training file which documented all completed mandatory training, competencies and any continued professional development. The registered manager reviewed and monitored these files to ensure all staff training and competencies were current.
The service’s recruitment documentation was kept electronically in one place. Staff files we reviewed on site contained all documentation required. DBS checks, references, identification, training competency certificates, application forms, induction to the service and appraisals.
The service policies were reviewed, in date, version controlled and reflective of the services provided. The service was completing audits, competency assessments for image quality and reporting, that now kept them in line with their own policies and national guidance.
Staff now followed protocols and guidance that was up to date for all scans provided by the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service focused on continuous learning, innovation, and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice, and research.

At the last assessment, 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.
The service did not have an effective system in place to seek and respond to staff and people's feedback. [BS27.1]
Improvements were seen at this follow up assessment. The service had an audit programme in place. The service no longer undertook any pregnancy related scans. This freed up time to enable the registered manager, a practicing sonographer within the service, to complete audits and have clearer oversight and governance of the service.
Staff now had policies and protocols that were up to date and in line with the services provided. This together with improvements in mandatory training, particularly around safeguarding, learning disability and autism, allowed them to provide a safer and better quality of care.
The service has fulfilled and completed all the areas that were stated in the Section 29 Warning Notices issued by the CQC and were no longer in breach of regulations