Fulwood Hall 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

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first time we have rated effective for diagnostic imaging at this location. We rated effective as good.

Staff worked well together and across services to support patients. Staff assessed patient’s needs and supported them to make decisions about their care. Staff followed national guidance to gain consent. Most patients experienced positive outcomes following their care and treatment.

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.

Admission policies were in place to provide guidance for staff around the assessments required prior to admission to the service.

Patients underwent an initial telephone assessment as part of the booking and referral triage process. Patient scan requirements, suitability for the scan procedure and arrangements for scan reporting were reviewed and discussed with them.

Patients told us staff carried out assessments prior to undertaking scan procedures to identify key risks and these took into account their needs and preferences.

The care records we looked at showed referral records and initial assessments were completed appropriately prior to commencing scans and patient risks, needs and preferences were reviewed and discussed with them.

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 clinical guidelines and pathways based on national guidance, such as from The National Institute for Health and Care Excellence (NICE), College of Radiographers, The Royal College of Radiologists and the British Medical Ultrasound Society (BMUS).

The service provided care and treatment based on national guidance including the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and the Medicines and Healthcare products Regulatory Agency (MHRA) safety guidelines for radiology imaging equipment in clinical use. Policies and processes were aligned with and referenced the Ionising Radiation Regulations 2017. Radiation protection policies and local rules for radiation safety were up to date and accessible by staff.

Staff used local safety standards for invasive procedures (LocSSIPs) and modified World Health Organisation (WHO) safety checklists when carrying out certain invasive procedures. Staff also followed ‘paused and checked’ safety prompts for ultrasound scan procedures, in line with BMUS guidelines.

Care pathways and clinical policies were benchmarked against national guidelines and developed through the corporate provider. The imaging manager and peripatetic imaging manager were involved in peer groups for imaging managers across the provider’s hospitals regionally and nationally and regularly attended meetings to discuss changes in practice and share learning. We saw evidence through departmental, hospital and provider level radiation protection, audit and diagnostic governance meetings that changes in practice and guidance updates relating to diagnostic imaging processes were routinely discussed.

Staff told us policies and procedures reflected current guidelines and were easily accessible through the provider’s intranet. We looked at a selection of the policies, procedures and care pathways and these were up to date and based on current national guidelines. Patients spoke positively about the way their scan procedures were undertaken and told us staff fulfilled their needs and 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.

We saw there was effective daily communication and team working between the radiology and administrative staff so scan procedures could be planned, coordinated and delivered effectively. Patients spoke positively about the way their scans were planned and coordinated. They told us the staff at the service worked well together as a team. Daily staff huddles and routine staff meetings took place so staff had up to date information about planning and delivery of scan procedures and any risks or concerns. Staff worked closely with the outpatient and surgery services across the hospital to plan and deliver services. They also routinely engaged with colleagues across the provider’s other hospitals.

Staff told us they were able to contact referring clinicians and consultant radiologists when needed. Consultant radiologists told us they regularly engaged with staff and provided support and guidance when needed. Managers routinely engaged with service partners and stakeholders to support the planning and delivery of scan procedures and scan reports.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing.

The imaging manager told us they did not routinely offer health promotion advice due to the specific and specialist nature of the diagnostic imaging services they provided.

The imaging manager confirmed they provided advice to patients verbally and in writing relating to their scan procedure and advised patients to contact their general practitioner or referring clinician if they required advice and support around healthier living.

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 themselves.

Patients spoke positively about the quality of the care and treatment they received. They told us they did not have any concerns about the quality of their scan images or reports.

The service did not participate in any local or national clinical audits or benchmark patient outcomes with any external organisations.

The imaging manager told us patient outcomes were measured by evaluating patient experiences, incidents and complaints. Patient feedback was mostly positive and the service had reported low numbers of incidents and complaints. This indicated that most patients had a positive experience and that their expected outcomes were being achieved.

The service had processes to peer review scan images and reports to gain assurance that scan procedures were carried out in line with national guidance and the provider’s policies. At least 10 records for each radiographer were peer reviewed every 6 months. Peer audit records over the previous 12 months showed at least 90% compliance had been achieved, demonstrating good levels of staff compliance.

An image quality audit was also undertaken to review the consistency and quality of scan images and reports at least every 6 months. The service achieved 90.5% compliance in November 2025 and 86.7% compliance during January 2026, compared with the provider’s compliance target of 90%. An action plan was in place to improve compliance.

Rejected scan images were routinely reviewed by the service to monitor performance and identify improvements. The percentage of rejected images ranged between 8.4% and 11.8% during November 2025 to March 2026. The most frequent reasons for rejected images were for positioning errors or clipped anatomies. Knee imaging accounted for most rejected images during this period, followed by hip and pelvis examinations. Individual radiographers received feedback on rejected images to aid learning and improvement. An action plan was in place to reduce rejected scan images through additional staff training, visual aids and prompts and through additional monitoring and focused peer reviews.

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.

The provider’s policy for ‘consent to treatment for competent adults and children and young people’ outlined the process for obtaining verbal and written consent from patients prior to undergoing scan procedures. All radiology staff had completed mandatory training in equality, diversity and human rights.

The diagnostic imaging service only provided scan procedures for patients over 18 years of age. Patients that were unable to give consent or had certain complex health conditions were excluded for admission to the service.

Staff told us if a person lacked capacity to make their own decisions (such as those living with dementia or a learning disability), then they would carry out an assessment with the referring clinician as part of the referral and booking process to determine if they could be admitted for scan procedures.

Staff told us they understood how to obtain informed verbal and written consent from patients before commencing scans. This included respecting their wishes if they refused treatment or withdrew their consent.

Patients told us staff asked for their consent prior to undertaking scan procedures and the risks and benefits of their scan procedure were clearly explained to them verbally and in writing. The patient records we looked at showed verbal and written consent had been documented appropriately.

Recent radiology consent record audits between September 2025 and April 2026 showed 100% compliance had been achieved for X-ray and ultrasound consent processes.

Self-funded and private insured patients told us the fees charged for undertaking scans were clearly explained to them as part of their initial booking information. Information about fees and charges was documented in the records we looked at.