Private Ultrasound Scan

Independent Healthcare Org · London

Overall Rating
Requires Improvement Last inspected 31 August 2022
Domain Ratings
Safe
Requires Improvement
Effective
Not Yet Rated
Caring
Good
Responsive
Good
Well-led
Requires Improvement

View Full CQC Report

7 must-do actions
3 should-do actions

Must-Do Actions (7)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The service must ensure that staff complete and update risk assessments for each patient.
Regulation 12 (Safe care and treatment)
Staff did not complete and update risk assessments for each patient, meaning vital information to assess risk was not recorded.
Must Do
Safe
The service must ensure that equipment used for providing care are safe for use and used in a safe way. This includes regular quality assurance testing of ultrasound scanners by sonographers.
Regulation 12 (Safe care and treatment)
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.
Must Do
Safe
The service must ensure that staff control infection risks well. This includes using appropriate sterile ultrasound gel in line with national guidelines and conducting infection prevention and control audits.
Regulation 12 (Safe care and treatment)
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.
Must Do
Well-led
The service must ensure policies are comprehensive and reflect current legislation and best practice guidelines in order to give staff guidance for decision making.
Regulation 17 (Good governance)
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comprehensive and did not reflect current legislation and best practice guidelines, with all policies reviewed being out of date, failing to give staff adequate guidance for decision making.
Must Do
Well-led
The service must ensure there are effective governance processes in place. This includes implementing systems for reviewing policies, protocols and procedures, and risks.
Regulation 17 (Good governance)
Effective governance processes were not in place, as there were insufficient systems for reviewing policies, protocols, procedures, and risks.
Must Do
Well-led
The service must ensure there are effective systems to monitor, escalate and mitigate risks appropriately.
Regulation 17 (Good governance)
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.
Must Do
Safe
The service must ensure staff maintain accurate and complete record in respect of each service user.
Regulation 17 (Good governance)
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.

Should-Do Actions (3)

Recommended improvements to enhance service quality.

Should Do
Responsive
The service should offer formal interpretation services for patients.
Should Do
Caring
The service should implement a chaperone policy and offer patients chaperones.
Should Do
Effective
The service should implement an independent review of scan procedures including those carried out by the lead sonographer.
Location Details
CQC ID: 1-10194284742
Local Authority: Hillingdon
Region: London
Inspection Report
Type: Comprehensive inspection
Date: 31 August 2022
Rating: Requires improvement
Actions: 7 must-do , 3 should-do
AI-extracted 17 Feb 2026