Buckshaw Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We found that patients achieved good outcomes because their needs were assessed and care was delivered in line with best practice. Referrals were appropriately reviewed, and care was planned to meet patients’ individual needs.

Care and treatment were delivered in line with national guidance, including the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and radiation safety standards. Patients typically attended for a single diagnostic appointment, with follow-up managed by referring teams, ensuring clear clinical responsibility and continuity of care.

Outcomes were monitored through audit and key performance indicators, which were generally good. Staff worked collaboratively, were appropriately trained and competent, and delivered coordinated, patient-centred care. Patient feedback was positive, and there was evidence of a culture of learning and continuous improvement.

At our previous assessment, this key question was not rated. At this assessment, this area was rated good. This meant patients received effective care and achieved good outcomes.

We have not awarded this service a score for Effective.

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

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff assessed patients’ needs and delivered care in line with established processes and clinical guidance. Referrals for MRI and CT were reviewed and justified by radiologists, ensuring appropriate clinical decision-making. Administrative and clinical checks supported safe booking, with staff having access to referral information prior to patient contact and examination.

The service had standard operating procedures and arrangements in place to support safe and effective care, including emergency transfer processes to NHS critical care services. The service worked under formal agreements with NHS providers and commissioners, supported by regular contract review meetings to monitor performance and patient care.

Patients were assessed prior to imaging using safety questionnaires, including MRI screening. We saw that patient demographics and referral information were checked and verified, and that all referrals were authorised by a radiologist. Where risks were identified, these were reviewed in advance and followed up before attendance. For example, patients with identified risks, such as implants, were contacted prior to their appointment to complete additional safety checks.

Staff described how patients with additional needs were supported, including those requiring interpreters, chaperones or adjustments for anxiety. We heard examples of patients receiving tailored support to meet their individual needs. For example, staff described supporting an anxious patient with autism by allowing additional time, using a quieter environment and enabling a relative to remain present during the scan to provide reassurance.

For CT imaging, additional assessments were undertaken where required, including blood tests prior to contrast dye administration for patients meeting specific criteria.

There were systems in place to escalate significant or unexpected findings. Staff described the use of an alert process, where radiologists notified the referring clinician of urgent findings and required acknowledgement to ensure results were reviewed and acted upon.

These processes supported the delivery of care that was appropriate to patient needs and based on clinical assessment, although some performance pressures were identified through contract monitoring arrangements.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies to plan and deliver care in line with recognised national guidance. Imaging protocols and clinical pathways reflected guidance from the Royal College of Radiologists (RCR), the National Institute for Health and Care Excellence (NICE), and relevant Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts. Staff told us they were routinely informed of updates to national guidance, and we saw that local procedures were reviewed to ensure they remained current.

Compliance with the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and Ionising Radiations Regulations (IRR) was supported through oversight from the radiation protection supervisor and corporate governance teams.

A structured audit programme was in place to monitor the quality and safety of imaging. Recent internal audits demonstrated high levels of compliance, including performance in the 50‑step imaging review, CT quality checks, MRI safety assessments and radiation protection inspections. Staff described how areas for improvement were recorded and monitored through governance systems, with actions reviewed in meetings to support ongoing improvement.

The service demonstrated a commitment to learning from incidents. Staff described how learning from an MRI-related safety incident at another site had been shared across the organisation through corporate communication channels. The service also participated in regular MRI safety meetings, radiation protection committees and a weekly patient incident response group to review incidents, themes and learning.

There were systems to support safe clinical decision-making and communication of results. Radiologists used structured approaches to highlight urgent or unexpected findings, including an alert system requiring referring clinicians to acknowledge significant results. Staff had access to relevant clinical information, including previous imaging and policies, through clinical systems, and received training in key areas such as MRI safety, contrast administration and IR(ME)R requirements.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff, teams and services worked well together to deliver coordinated care. Radiographers, radiologists and administrative staff communicated effectively to ensure referrals were reviewed, safety information was shared, and patients were appropriately prepared for imaging.

Radiographers, radiologists and other staff worked together as a team to benefit patients. Radiologists were available to provide clinical advice and support decision-making, and significant findings were escalated through established processes to support timely follow-up. This ensured staff could share relevant information and support continuity of patient care.

Multidisciplinary working was supported through structured governance and safety meetings. Quarterly MRI safety meetings and radiation protection committees brought staff together to review safety issues, discuss compliance with regulatory requirements and share updates. A weekly patient incident response group alternated between sites and provided a forum for reviewing incidents, identifying themes and agreeing actions.

Radiographers and radiologists worked collaboratively to maintain imaging quality. A structured feedback process enabled radiologists to provide feedback on image quality, supporting consistency and continuous improvement across the service.

Staff described positive working relationships across teams and told us they felt able to seek advice and support when required.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service provided information to support patients to prepare safely for imaging and understand their care. Patients received information in advance of their appointment, including preparation requirements and safety considerations, which helped reduce delays and support safe attendance.

Information leaflets were available within the department for a range of imaging procedures. These supported patients in understanding what to expect during their visit and how to prepare appropriately for imaging.

Staff were available to answer questions and provide additional guidance, supporting patients to understand their procedure and what would happen during their appointment.

Significant findings were communicated promptly to referring clinicians to support timely follow-up and ongoing care.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people.

Staff monitored the effectiveness of care and treatment through audit activity and key performance indicators (KPIs). Audit results demonstrated high levels of compliance, and where improvements were required, actions were implemented and monitored to ensure changes were embedded.

The service participated in external quality assurance processes, which provided independent oversight of reporting quality. Results from these processes demonstrated consistently high standards and supported ongoing improvement.

Performance against key performance indicators, including reporting turnaround times, was monitored regularly. Staff were aware of targets and prioritised work accordingly to ensure timely reporting of results.

Findings from audits and performance monitoring were used to support improvements within the service, with actions tracked through governance processes to ensure completion and sustained improvement.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff supported patients to make informed decisions about their care and treatment. The service had effective processes in place to ensure consent was obtained in line with legal and professional requirements. A consent policy for adults and young people was in date and available to staff. The service provided diagnostic services for patients aged 18 and over.

Staff ensured patients were provided with clear information prior to imaging, including details of the procedure and preparation requirements. Staff completed pre-scan questionnaires with patients in a private setting, allowing sensitive information to be discussed appropriately and supporting informed consent.

Staff were familiar with the Mental Capacity Act and followed established processes for assessing capacity and supporting decision-making. The service had an up-to-date Mental Capacity and Deprivation of Liberty Safeguards policy in place. Where patients were unable to provide consent, best interest decisions were made in line with guidance, and staff had access to additional support, including Independent Mental Capacity Advocates (IMCAs) where required.

Staff were able to support patients with additional needs, including access to interpreters and chaperones, helping to ensure consent was informed and appropriate.

Consent practice was monitored through audit. A whole hospital medical records consent audit completed in October 2025 demonstrated 97.2% compliance, providing assurance that consent processes were generally followed.