Private Ultrasound Scan

⚠ Staff did not complete and update risk assessments for each patient, meaning vital information to assess risk was not recorded.

⚠ Equipment used for providing care was not always safe for use, as the service did not complete regular quality assurance testing of ultrasound scanners in line with British Medical Ultrasound Society (BMUS) guidelines.

⚠ Staff did not always control infection risks well, including using ultrasound gel from five litre dispensers decanted into refillable bottles contrary to national guidance, and not conducting infection prevention and control or hand hygiene audits.

⚠ Policies were not comprehensive and did not reflect current legislation and best practice guidelines, with all policies reviewed being out of date, failing to give staff adequate guidance for decision making.

⚠ Effective governance processes were not in place, as there were insufficient systems for reviewing policies, protocols, procedures, and risks.

⚠ Effective systems to monitor, escalate and mitigate risks appropriately were not in place, as leaders and teams did not always identify and escalate relevant risks and issues, and the service did not have a risk register.

⚠ Staff did not always maintain accurate and complete records of patients’ care and treatment, with some patient history and consent forms unsigned, lacking medical history details, or not specifying the scan performed.