George Eliot NHS Hospital

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

We assessed a total of 5 quality statements from the safe, responsive and well-led key questions and found areas of good practice. The scores for these areas have been combined with scores based on the key question ratings from the last inspection. The assessment of these five quality statements indicated areas of improvement and good practice since the last inspection, our overall rating remains good. The service had improved. Staff consistently completed their mandatory training , including safeguarding children and safeguarding adults training. The department was using a computersied reporting system to check that all plain film scans (x-rays) had been reported on. Safe We reviewed the learning culture, safeguarding, involving people to manage risks, safe environment, safe and effective staffing, infection prevention and control and medicines optimisation. Learning Culture: The service provided safe care and treatment based on national guidance and best practice. There was evidence that the service learned from incidents. Safeguarding: Staff received training on how to recognise and report abuse and they knew how to apply it. Involving people to manage risks: The service provided information about the type of imaging they offered including the side effects of radiation. This enabled people to make decisions about their care and treatment. Safe environment: Staff carried out daily safety checks of specialist equipment to ensure it was in good working order. The service had suitable facilities and equipment to safely meet the needs of patients and their families. Safe and effective staffing: The service had enough staff but relied on bank and agency staff to fill gaps in staffing levels. Infection prevention and control: We saw staff followed guidance on IPC and PPE. Medicines optimisation: Medicines were mostly well managed however, the stock check in IR had not been completed for 1 month and there were out of date medicines in the medicine cupboard.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff at all levels told us they worked in a learning rather than blame culture, they said this encouraged them to report and learn from incidents. The service was developing a range of radiographer led clinics, this was enabling staff to develop new skills as well as reducing waiting times for treatment. Staff understood how to apply the duty of candour and they knew the system to follow to do this. They would inform the radiation protection supervisor in the first instance and then offer a full apology to the patient with an explanation of what went wrong and why.

The service provided mandatory training in key skills to all staff and made sure everyone completed it. Overall compliance with mandatory training in April 2024 was 93%. The service managed patient safety incidents well. There were processes in place for staff to follow when reporting incidents, including reporting to external bodies. Incidents were discussed as part of regular huddles and meetings, and where learning was required, there were processes to follow for staff to ensure this was shared and embedded. Radiologists held a monthly learning meetings where they looked at exceptions and clinical incidents. During April 2024 26 incidents were reported, 18 incidents that caused no harm to patients, 7 that caused low harm and 1 that resulted in moderate (short term) harm. There had been 1 incident that resulted in severe harm in the 12 months before our inspection. We saw incidents were reported to IR(ME)R in line with regulations. The service could demonstrate how they learnt from complaints. In the 12 months before our inspection 3 complaints were received by the service, all 3 were for potential misdiagnosis. To reduce the likelihood of misdiagnosis the service ensured a radiologist was available 7 days a week for support with vetting referrals and reporting, and out of hours support was available through a teleradiology service. Managers ensured that actions from patient safety alerts were implemented and monitored.

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.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and work with other agencies to protect them. Staff knew how to make a safeguarding referral, and who to inform if they had concerns. Staff gave us examples of when they had contacted both internal and external safeguarding teams.

The service had a safeguarding policy that included a flow chart of steps to take and the telephone numbers of external safeguarding teams so staff knew who to contact if they had a concern. Staff received training specific for their role on how to recognise and report abuse. Data provided to us following our assessment showed the 85% compliance target was exceeded for training in level 1 and level 2 safeguarding adults and safeguarding children. Compliance with level 3 safeguarding adults and level 3 safeguarding children was 100% for all modalities apart from ultrasound were compliance stood at 50%, this translated to 3 members of staff who required the level 3 safeguarding qualification. However, in mitigation there was a high level of level 3 trained staff available to give support within the department. There was a separate waiting area for children in the main radiology department. The waiting area was well equipped with toys, books and activities. This created a suitable environment for families.

Patients told us they had been given information about the side effects of radiation and had been provided with personal protective equipment (PPE) to reduce the likelihood of them receiving more radiation that was required during their scan. For example, lead lined aprons were given to patients to wear during plain film imaging (x-ray).

Each radiology modality had its own set of local rules and other safety protocols so that all staff were aware of their responsibilities and who to contact if something went wrong. Staff also used local protocols to cover their practice, these contained clear instructions which were easy to understand. Each modality had its own equipment and image quality assurance framework. We saw record keeping, referrals and vetting was in line with Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R). Staff followed the Royal College of Radiologists standards for intravascular contrast agent administration including observation of patients for 20 minutes following the use of contrast. Staff followed the Society of Radiographers ‘pause and check’ guidance when checking patient’s identity before administering injections or scanning patients. There were leads for Local Safety Standards for Invasive Procedures and National Safety Standards for Invasive Procedures. We saw staff using a World Health Organization safer surgery checklist modified for use in radiological settings. Staff in MRI received training on identifying specific risks such as pacemakers or metal implants. The service ensured staff were aware of patients who were or may be pregnant, in accordance with IR(ME)R, and Ionising Radiation Regulations (IRR) 2017. We saw posters displayed in patient areas asking patients to speak to a member of staff before they were scanned if they may be pregnant. The service ensured that the radiation protection advisor and the medical physics expert were easily accessible to staff requiring radiation advice.

The service had an Ionising Radiation (Medical Exposure) Regulations 2017 procedures policy. It included the request criteria, providing benefit and radiation risk information to patients, exposure charts, reporting of radiological images, use of equipment, and how to contact the radiation protection advisor and the medical physics expert. Each modality also had its own standard operating procedure. Regular radiation protection audits were carried out to assess local compliance with the Ionising Radiation regulation 2017 and the Ionising Radiation (Medical Exposure) Regulations 2017 the audits included a review of patient safety management processes. There were clear processes to escalate unexpected or significant findings both at examinations and upon reporting. There was a clear pathway and transfer policy for the management of patients using services within the radiology department who were clinically unwell and required hospital admission. All requests for imaging were entered onto the radiology information system. The service ensured imaging requests were appropriate and included the relevant information to allow for requests to be justified in accordance with Ionising Radiation (Medical Exposures) Regulations (IR(ME)R). All 5 of the patient request forms we reviewed contained the required information including patients’ medical history, and the clinical indication for the scan. The booking team referred requests that did not contain this information back to the referrer. Senior radiologists vetted the requests prior to appointments being issued. Reporting was undertaken by a mix of in-house radiologist, radiographers and external teleradiology services. The service stored images on a Picture Archive Communication (PAC) system. Reports were sent to refers through the PACs system and were emailed to referrers who did not have access to the PAC system.

Patients were given PPE to keep them safe during scanning. Patients told us they had been given information so they knew what to expect during their scan, this included information about the risks of radiation.

Staff told us they carried out daily safety checks of specialist equipment including CT scanners and X-ray equipment. The CT equipment was not useable until a safety check (calibration) had been performed at the start of each day. Staff carried out a daily quality assurance process for the MRI scanners. Staff told us that when equipment was found to be broken, they removed it from the area, labelled it as faulty and logged this with the estates team. Staff received training on imaging equipment when they started within the trust. There was a practice educator who ensured staff were competent to use equipment and also had opportunities to develop in their roles.

The service had suitable facilities to meet the needs of patients' and their families. There were enough seats for patients to bring their family/carers and the waiting areas were spread out. All of this equipment in the CDC was new. The environment was visibly clean, it was also spacious light and airy. The building was fully accessible. The main radiology department was visibly clean and had suitable furnishings which were clean and well-maintained. Some of the equipment in the radiology department in the main hospital building was old although well maintained. There were plans to refurbish some of the rooms within the next 12 months and replace some of the imaging equipment. There was not a dedicated recovery area in interventional radiology for patients who had undergone a produce under an aesthetic. However, there were arrangements with the medical and surgical departments for patients requiring recovery care to be looked after there. Resuscitation equipment was readily available, adequately stocked and there was evidence of regular review. The resuscitation equipment we saw was clean and in good condition. The radiology department and CDC ensured areas where ionising radiation was used were controlled and access was restricted. Warning signs were present on all rooms using ionising radiation and the MRI scanner door had a key code lock which prevented any unauthorised or accidental access. We saw the facilities and equipment were well maintained and used for intended purpose and used properly. All equipment we checked had an up-to-date electrical safety check. Staff disposed of clinical waste safely. We saw a wall mounted fire extinguisher with an empty trolley for storing patient records in front of it. This meant staff may not have seen the fire extinguisher in the event of fire. We raised this issue with staff who immediately moved the trolley and said they would ensure the notes trolley was not stored there in future.

There were systems to check the image quality of scans and a process for staff to follow if image quality was below standard.

The service had enough staff to keep patients safe however, senior leaders told us recruitment and retention could be a challenge due to general NHS staffing shortages. Out of hours the service used teleradiology services for reporting, and staff had access to these radiologists for queries and advice. The service had recently recruited 5 radiologist fellows from overseas. It was anticipated these fellows would speed up reporting time on images taken within the department and allow the department to stop using the third party out of hours teleradiology service. The management team included radiologists and radiographers, and quality assurance managers. Each modality had a lead superintendent radiographer supported by senior radiographers. Staff told us emergency scanning for theatre meant staff in x-ray sometimes had to leave the department to perform an x-ray elsewhere. Staff said this could make it feel like there were not enough staff in the department. Locum staff told us there was not a fixed time length for an induction when they joined the service, they said it could last a day or a week. One of the locum radiologists we spoke to was unaware of the decontamination process used in the department as this had not been covered in their induction. We saw information provided by the trust which showed a radiographer working in x-ray had not received information about where the reference grid was as part of their induction. To improve access to the service a number of radiographer led clinics and interventions had been introduced. As well as reducing waiting times this meant staff were provided with development opportunities.

The service employed a practice educator on a part time basis. The practice educator was responsible for ensuring staff had the correct competencies to carry out their role. They organised training for staff who wanted to progress in their role or develop new skills. The department was funding training opportunities for several staff at the time of our inspection. New staff were put on a preceptorship programme to ensure they had the necessary competencies to carry out their role. The preceptorships for internationally recruited staff ensured their competencies aligned with UK standards. There was a separate (local) induction for each modality. The induction process lasted between 8 and 12 weeks. The inductee had their competencies signed off during this period. A buddy was assigned to each new starter for their first 12 weeks in post, this meant there was always a named person the inductee could approach for help and support. The Trust had introduced specific training on recognising and responding to patients with learning disabilities and autism in line with national guidance introduced in September 2023. However, only 75% of staff across radiology had completed this training at the time of our assessment. This meant not all staff had the knowledge they needed to support these cohorts of patients. Overall compliance with appraisals was 85%, with some staff groups achieving 100% compliance and others, for example the radiology administration team only achieving 63.64% compliance. The mandatory training the service provided was comprehensive and met the needs of patients and staff. Staff had completed and kept up to date with their mandatory training. Compliance with mandatory training in the department was 95% which was higher than the trust’s 85% acceptable compliance rate. Staff had access to a system that clearly displayed when their training was out of date.

Staff told us they used infection control measures when carrying out x-rays or scans where people had or were suspected of having infectious or communicable diseases. Deep cleans of scan rooms were available from the onsite cleaning team on request. However, we saw information provided by the trust which showed in March 2024 a porter brought a patient with a communicable disease into the department for an ultrasound scan. The patient was brought into the scan room before staff were made aware the patient should have been seen at the end of the clinic. Staff reported this as an incident so learning could be shared with other staff in the hospital. Staff told us they cleaned the room and equipment in between patients. The hospital domestic team cleaned the department each evening.

Clinical areas were visibly clean and had suitable furnishings which were clean and well-maintained. We watched a member of staff decontaminate an ultrasound probe used to scan intimate areas. They correctly used the decontamination chamber but did not take the sticker with the cycle number to record in the patient notes. Best practice would have been for the cycle sticker to be added to the patient notes, this was in case in the future there was an infection prevention and control issue that meant patients needed to be recalled. Some staff were recording decontamination cycle stickers in patient notes while others were not. We raised this as an issue with the manager for ultra sound. They assured us staff had received training on this issue from the decontamination chamber manufacturer’s representative the previous week and from the following week all staff would be required to record the decontamination cycle in patients notes. Sterile gel was used for ultrasound procedures to reduce the risk of infection. We saw staff in X-ray disinfect the examination room following each procedure. Patient gowns were collected in a used gown collection bin as soon as the patient had changed back into their own clothes. This was to ensure each gown was only worn by 1 patient.

The quality manager performed an audit of the environment each month, the audits showed areas that required improvement which were sent to the estates department or domestic services team for immediate action. Some issues, for example, extensive wear in some areas of flooring could not be resolved immediately and became part of a long-term improvement plan while a temporary solution (hard wearing tape covered damaged/worn flooring to prevent a trip hazard, the tape was washable).

Medicines storage was locked and secure with access only to authorised staff. However, medicines were not always checked to ensure they were within their expiry date. We observed that some medicines in the interventional radiology suite were out of date and had not been removed for destruction. There was a stock list available which documented all the expiry dates, but it had not been checked since 19th March 2024. Oxygen cylinders were stored in the PACS records Office. We observed that the cylinders were stored upright with warning signage in place. However, the cylinders were blocking access to the electrical switch room doors. We raised this as a concern and an alternative storage was immediately identified for future storage of medical gases. Controlled drugs (medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by two staff daily. Checks of CDs showed that they were within date and stock balances were accurate. Medicines for refrigeration were stored securely with records available of maximum and minimum temperatures to ensure the medicines were stored safely.

The department had processes for the storage and management of medicines including the designation of specific staff to access controlled drugs.