Buckshaw 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 found that safety was a priority within the service, with leaders promoting a culture of openness and learning. Staff understood how to raise concerns and report incidents, and learning was shared to improve practice.

Patients were protected from avoidable harm through effective systems and processes. Staff followed appropriate safety checks prior to diagnostic procedures to ensure the correct patient received the correct imaging, and risks were identified and managed appropriately.

Staff understood safeguarding processes and their responsibilities in protecting patients from harm. The environment was clean, well maintained and supported safe care delivery.

At our last assessment, this area was rated good. At this assessment, the rating has remained good. Patients were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well. Staff within diagnostics recognised and reported incidents and near misses using the electronic RADAR system, in line with local procedures. Staff told us they felt confident using the system and described a “close the loop” approach, where feedback was shared once incidents were closed, including emails circulated to all staff to support learning.

Managers investigated incidents and ensured lessons learned were shared across the service. We saw that learning was embedded and consistently reinforced through daily safety huddles in the morning and team meetings. These forums were used to discuss incidents, identify system issues, and agree safety actions.

The service had established processes to review incidents and drive improvement. Diagnostics lessons learned were reviewed monthly, with the quality improvement manager coordinating shared learning, contributing to governance processes, and supporting policy reviews. Updated policies were escalated through the policy committee and governance systems.

We saw evidence of structured learning loops, where incidents were used to identify system issues, implement safety actions, and inform safety improvement plans. Learning was shared through a monthly diagnostic governance and shared learning report, as well as through cross-hospital sharing, supporting wider organisational learning.

Hot debriefs were undertaken following serious incidents to support reflection and staff wellbeing. Staff described a positive and proactive learning culture, supported by structured induction, a supervised period, and a three-month probationary process.

An increase in incident reporting over the past 12 months indicated improved staff confidence in reporting and a strengthening safety culture within the service.

The service had reported no ‘Never Events’ in diagnostics. This indicated that safety systems and processes were embedded, and that staff consistently followed established procedures

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had clear and robust systems and pathways in place to ensure patients were referred, vetted and booked safely across all diagnostic modalities. MRI referrals were received through the electronic referral system and transferred into the radiology information system, where administrative staff completed initial checks before sending requests to radiologists for electronic justification and appointment allocation.

Private patients were contacted directly, and any prescriptions required for contrast dye were arranged prior to booking.

CT referrals followed a similar process, with administrative checks, radiologist vetting and prescription management. Patients aged over 75 were required to have kidney function tests completed before appointments were confirmed. For ultrasound, referrals were reviewed by sonographers to determine preparation requirements and ensure appropriate scheduling.

We saw evidence that patient demographics were consistently checked, referral information was complete and appropriately vetted, and prescriptions were arranged where required. This provided assurance that patients were appropriately assessed prior to imaging and that risks were identified and managed.

All patients completed safety questionnaires, including MRI safety forms sent with information booklets; any responses indicating potential risk, such as implanted devices, were reviewed in advance and followed up with a safety call prior to attendance. Urgent referrals were escalated directly by consultants and prioritised accordingly.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff demonstrated a clear understanding of safeguarding responsibilities within a diagnostic imaging environment and were confident in recognising and escalating concerns.

The service had up-to-date safeguarding policies that were accessible to staff and reflected current guidance. The service had access to a Level 4 safeguarding lead who provided oversight and support.

Staff received safeguarding training appropriate to their role. Safeguarding training compliance was high overall, with compliance rates reaching 95% for face-to-face training and 98% for e-learning. Within the service, compliance exceeded 98% for safeguarding level 1 and 2 and children’s safeguarding. Radiology staff had achieved 100% compliance with Level 1 and Level 2 adult safeguarding training and Level 3 children’s safeguarding training. Compliance with Level 3 adult safeguarding face-to-face training was 43% at the time of inspection.

Leaders told us, that the service had gone through a period of positive culture change in which a number of staff had left the provider and new staff were recently onboarded. This is the reason for the low 43% in level 3 adult safeguarding. Leaders had an action plan in place to address this low figure.

Safeguarding topics such as female genital mutilation (FGM), human trafficking, Prevent, mental capacity and modern slavery were embedded within training programmes. Although children were not treated on site, children’s safeguarding training was included in compliance monitoring.

Staff knew how to make safeguarding referrals and described the processes they would follow if they had concerns. We saw evidence of safeguarding referrals being completed appropriately. Debriefs were undertaken following recent referrals to support learning and reflection.

Safeguarding concerns were considered when incidents occurred, and appropriate actions were taken. Staff had access to competency documents to support their safeguarding knowledge and practice. Visual prompts, including posters relating to FGM and Prevent, were displayed in clinical areas to support staff awareness.

The registered manager had oversight of safeguarding activity within the service. Safeguarding and training performance was monitored through monthly training and development meetings attended by trainers and senior leadership, where delivery, challenges, and performance data were reviewed.

These systems and processes demonstrated that safeguarding was embedded within everyday practice and that staff were supported to identify, escalate and respond to concerns appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked with patients to understand and manage risks. Staff involved patients in understanding risks throughout their care, with risks and individual needs identified at referral and prior to attendance. Adjustments were made where required to reduce delays or barriers to care, supporting patients to safely access the service.

Safety screening forms were used to identify risks, including pregnancy status, and signage was displayed within the department to remind patients to inform staff if they may be pregnant. Staff ensured patients were informed about their scan, preparation requirements and what would happen next.

We spoke to five patients during the assessment. Four told us they felt listened to, well informed and supported to understand their care and any associated risks, including next steps and follow-up where required.

Staff provided examples of how risks were managed in practice. Incidents included a cancelled scan where an interpreter had not been booked, and a delayed appointment where the interpreter arrived late. These demonstrated how communication needs were considered within the patient pathway.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design, maintenance and use of facilities, premises and equipment kept people safe. The environment was clean, well maintained and suitable for the delivery of safe care. Clinical areas were organised to minimise risk, with clear signage in place to support safety, including ionising radiation and MRI safety requirements.

The department was located on 1 level, with wide, clean corridors and a bright and open environment. There was a main waiting area and additional sub-waiting areas within diagnostics. Accessible facilities were available, including disabled toilets and multiple disabled parking spaces close to the entrance. Patients also had access to information leaflets located near reception.

The service had sufficient and appropriate equipment to support patient care, including MRI, ultrasound and CT scanners. Equipment was appropriately managed through planned preventative maintenance systems. Services were managed through asset registers and internal systems which provided advance notification of servicing requirements. Preventative and planned maintenance was scheduled proactively and communicated to staff.

We saw evidence that equipment was checked, faults were reported and escalated appropriately, and no equipment in use was overdue for servicing. Staff were familiar with how to raise service requests and access support. Service records were maintained centrally and within the department, and handover forms were used when equipment was transferred to engineers for servicing and testing.

There were systems in place to manage equipment faults. Staff described incidents where equipment issues, including a fault affecting the MRI scanner, had been reported and escalated through appropriate channels, although delays in engineer availability had impacted service capacity. Equipment not currently in use was removed or appropriately stored, including items identified as out of date during inspection.

Environmental and radiation safety were supported through appropriate oversight arrangements, including access to specialist advice. Audit results demonstrated high levels of compliance with safety standards, including 99% compliance in the 50 Steps audit, 99% for CT audit inspection, 98% for MRI inspection, 93% for IRR audit and 98% for safe and secure inspection. Fire risk assessments were in date.

Emergency alarms were tested weekly, and fire plans were in place and suitable for the service. Staff maintained a safe environment and followed relevant safety protocols.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe and provide appropriate care and treatment. The team included a deputy radiology manager, two radiographers, one radiography assistant and three administrative staff. At the time of inspection there was one radiographer vacancy and two assistant vacancies.

Staffing levels were generally sufficient to meet patient needs, and staff told us the service was able to run safely on a day-to-day basis. During periods of increased demand, staff worked collaboratively, including the use of extended working hours to maintain safe patient care.

There were some vacancies within the team; however, leaders had taken steps to manage this, including ongoing recruitment and the use of additional staffing where required. Agency use within radiology had been higher between August and November 2025 to support extended working hours and reduce patient waiting times, with total agency usage of 1,846.00 hours in 2025. This reduced significantly in early 2026, with 150.50 hours recorded across January and February, supported by reduced sickness and new appointments to posts.

Sickness absence across the hospital showed variation over the previous 12 months, with lower rates in March 2025 and September at 5%, and higher rates in November 9%, December and February, where rates remained above 8%. Staff turnover across the site had improved, decreasing from 21% in March 2025 to 12% in February 2026.

Staff were appropriately trained and competent for their roles. All radiographers held practising privileges, with clear processes in place for gaining accreditation to work within the service. A medical advisor sat on the board, providing clinical oversight.

New staff completed a structured induction tailored to their role. We saw evidence of a completed induction checklist. This included a two-week supervised period with a senior radiographer and a three-month probationary period. As part of the induction, staff undertook training in key areas such as radiation safety, MRI safety and recognition of significant clinical pathologies. Staff were also introduced to key safety information, including local rules, radiation protection supervisors and relevant policies and procedures.

Staff competency was assessed and recorded, including through the Provision and Use of Work Equipment Regulations (PUWER) and Lifting Operations and Lifting Equipment Regulations (LOLER), with staff required to demonstrate competence and sign off training before using equipment.

Staff told us they felt supported in their roles by colleagues and leaders. Patients did not raise concerns about staffing levels or staff competence.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service managed infection prevention and control risks well. Staff used equipment and control measures to protect patients, themselves and others from infection. There was an up-to-date infection prevention and control (IPC) policy in place, aligned with national guidance and accessible to staff.

The department was visibly clean, tidy and well maintained, with wide, open corridors and suitable furnishings. We observed no concerns regarding cleanliness within the clinical environment. Handwashing facilities were available, with signage in place to promote good hand hygiene, including reminders at handwashing basins. Patients we spoke with told us they had no concerns about cleanliness.

Staff followed appropriate infection prevention and control practices, including hand hygiene. Staff understood their responsibilities in maintaining a clean and safe environment.

The service monitored infection prevention and control through audit activity. Environmental infrastructure audit results from October 2025 demonstrated an overall compliance score of 97.3%. Water testing, including shower cleaning, was completed and documented. However, audit activity was primarily undertaken at whole-hospital level and was not specific to diagnostic imaging.

There were systems in place to identify and respond to infection prevention and control risks. There had been three IPC incidents reported across the hospital in the previous 12 months. Two incidents identified no gaps in care, and for the third an action plan, standard operating procedure and additional staff training had been implemented.

These processes supported the management of infection risks within the service, although opportunities remained to strengthen local oversight and sharing of audit findings within the department.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had systems and processes in place to safely manage medicines. Medicines were stored securely, with temperature monitoring records maintained to ensure they were kept within safe ranges. We saw evidence that temperature checks within radiology were completed consistently, with 100% compliance recorded in February 2026, with no gaps or out-of-range results. Equipment used to monitor temperatures was calibrated annually.

The service followed a medicines management policy which was in date and aligned with relevant guidance. Medicines were ordered and managed through structured stock control processes, with minimum stock levels maintained and reviewed six-monthly to ensure appropriate availability.

Staff followed standard operating procedures for the management of medicines. Patient Group Directions (PGDs), which are written instructions that allow specified healthcare professionals to supply or administer medicines to groups of patients without a prescription, were in place. However, these were not yet in use within the service, as staff training and competency assessments were still being completed. Staff were required to be authorised and included on a formal register before administering medicines under PGDs.

There were systems to ensure medicines were prescribed, administered, recorded and stored safely. We saw evidence that assessments were undertaken to support the safe use of medicines, including where contrast was required.

Medicines governance processes were in place. Audit results for safe and secure medicines management showed compliance above 90% within radiology over the previous 12 months, with recent results of 100% and 98%. A medicines governance inspection in February 2026 reported 89.5% compliance, with actions identified relating to refresher training for staff returning from absence.

There were clear arrangements for the use of unlicensed or off-licence medicines, which required approval through governance processes and were recorded on a central database subject to annual review. Learning from medicines issues was shared more widely, including through governance meetings, to support improvement across services.

The service did not use controlled drugs within radiology.

These arrangements supported the safe management of medicines, although further embedding of training and competency processes, including for PGDs, was required.