Fulwood Hall Hospital

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

Our rating of safe improved. We rated safe as good.

The service had enough staff to care for people and keep them safe. Staff understood how to protect people from abuse, and managed infection prevention and control risks well.

Staff assessed risks to people and acted on them. The service had oversight of safety incidents and learned lessons from them.

Premises and equipment were clean and well-maintained. The service had made improvements to address a regulatory breach relating to the cleaning and maintenance of radiology equipment during our previous inspection in December 2018.

However, the service did not consistently ensure that all staff, particularly consultants with practising privileges and bank staff, were up to date with mandatory training requirements.

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 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 identify and embed good practice.

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses using an electronic incident reporting system, in line with the provider’s incident reporting policy.

Staff used the patient safety incident response framework (PSIRF) to aid learning and improvement in line with the provider’s patient safety incident response policy. Incidents were reviewed and investigated by staff with the appropriate level of seniority, such as the imaging manager and the head of clinical services.

Patients told us they felt safe and did not have any concerns around safety incidents.

There had been no patient deaths or never events reported by the service during the 12 months prior to our inspection. Never events are serious safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious harm or death but neither need have happened for an incident to be a never event.

There had been 13 incidents reported by the diagnostic imaging services between May 2025 and April 2026. The most frequent incidents were for clinical reasons (11 incidents) such as patient complications and scan procedure issues. 2 incidents were related to communication issues.

One incident reported in October 2025 had resulted in moderate patient harm following a delay in reviewing and reporting scan results. A patient safety incident investigation had been completed and actions had been implemented to aid learning and improvement. Remedial actions undertaken included additional staff training and awareness and improvements in reporting and communication for radiology pathways and specimen ordering pathways.

The remaining 12 incidents had resulted in no or low patient harm. We looked at the incident reports for 5 of these incidents. These showed each incident had been appropriately investigated and improvement actions were implemented and shared with staff to aid learning and minimise reoccurrence.

Staff received feedback following incident investigations. Staff met to discuss the feedback and look at improvements to patient’s care during daily safety huddles and routine staff meetings so learning could be shared. Learning from incidents was also shared through hospital-wide alerts, bulletins and briefings to aid learning and improvement.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. We saw that formal duty of candour had been completed following the moderate harm incident reported in October 2025.

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.

The diagnostic imaging service had operational policies that provided guidance for staff around the booking, admission and discharge of patients undergoing scan procedures. Patients told us they were kept informed about their care and treatment at all stages, from their initial booking through to their scan procedure and reporting of their scan results.

Patients were referred to the diagnostic imaging service by authorised referring clinicians, including consultants, general practitioners (GP’s) and allied healthcare professionals, in accordance with the hospital’s inclusion criteria and Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) requirements. The referring clinician retained clinical responsibility for the patient. 

The service had policies for staff to follow if a patient became unwell during their scan procedure. All the radiology staff had completed basic and intermediate life support training.

Staff understood how to manage patient risks during an emergency. There were policies and procedures in place for the management of patients whose health deteriorated during scan procedures. Where a patient’s health deteriorated, diagnostic imaging staff were able to contact the resident medical officer (RMO), who was on site 24 hours per day and was trained in advanced life support. Staff could also contact the hospital-wide multidisciplinary resuscitation team during an emergency.

The service had an arrangement with local NHS trusts to enable patients whose health deteriorated to be promptly transferred to a local acute hospital if needed. There had been no instances where a patient required emergency transfer to hospital during the 12 months prior to our inspection.

Staff kept detailed records of patients’ care and treatment. Records such as consent forms were in paper format and these were scanned electronically on to the provider’s IT system. Diagnostic scan results, reports and images were stored electronically and could be accessed by staff in other parts of the hospital, such as during routine outpatient consultations. Scan images and reports were securely shared with referring clinicians electronically. We looked at the diagnostic imaging records for 8 patients. These were complete and up to date with few omissions or errors.

A patient records audit was undertaken every 6 months. The service achieved 94% compliance in the most recent medical records audit in March 2026, demonstrating good staff compliance.

Staff also carried out routine diagnostic scan process audits either every 6 months or annually depending on the type of audit. The audits covered aspects of governance, record keeping and image reporting processes. Audit results between July 2025 and April 2026 showed the service achieved high levels of compliance for X-ray (96.8%), MRI (95.9%) and ultrasound (100%) processes. Action plans were in place to improve areas identified in the audit findings and these were followed up by staff.

We scored the service as 3. The evidence showed a good standard. The service 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 could access policies for the protection of adults at risk of abuse or neglect and for safeguarding children. These provided guidance for staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as local authority safeguarding teams. Staff could also access safeguarding ‘grab bags’ which included relevant guidance and resources if required.

Patients told us they felt safe and were confident they could raise any safeguarding concerns they had with the staff.

Staff told us they had received safeguarding training and understood how to identify abuse and report safeguarding concerns. They told us learning from any reported safeguarding incidents was shared as part of daily huddles and during routine staff meetings and hospital-wide clinical governance meetings. We saw evidence of this in the meeting minutes we looked at.

Staff completed training specific for their role on how to recognise and report abuse, in line with current intercollegiate guidance for adults and children. Records showed 100% of the administrative staff, healthcare assistants, radiographers and sonographers had completed level 1 and level 2 adult and children’s safeguarding training. Records showed most (77.8%) consultant radiologists working under practicing privileges had also completed this training.

Training in the Mental Capacity Act, deprivation of liberty safeguards (DoLS), prevent (anti-radicalisation) strategy, modern slavery and female genital mutilation was also incorporated into the adult and children’s safeguarding training.

Staff could seek advice and support from the departmental safeguarding link lead and the hospital-wide safeguarding lead, who had completed level 3 safeguarding training for adults and children.

There had been no safeguarding incidents reported by the diagnostic imaging service during the 12 months prior to our inspection.

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 assessed and managed risks to patients and themselves well.

The referring clinicians carried out an initial patient assessment and information such as patient details, scan requirements and needs and preferences were sent to the service as part of the referral process. The administrative staff carried out an initial telephone assessment for each patient as part of the booking and referral triage process, to arrange a scan appointment and to discuss key risks and patient’s needs and preferences.

Patients also completed a medical history questionnaire to identify any potential risks prior to their scan. Any discrepancies in the referral or booking information or patients identified with specific medical conditions, such as epilepsy or pregnancy, were escalated to the imaging manager or radiographers to determine if it was appropriate to undertake the scan procedure.

The provider’s inclusion and exclusion criteria provided guidance for staff, so they could assess whether patients were suitable to undertake scan procedures. Patients under 18 years of age, those with complex health needs or severe mobility difficulties were not eligible for admission to the service.

Staff carried out patient risk assessments prior to undertaking certain scan procedures, such as magnetic resonance imaging (MRI). Pregnant patients, those that had undergone surgery recently and those with implants were assessed to determine if they were suitable to undertake MRI scan procedures. There were no specific requirements for patients undergoing X-ray or ultrasound scans, however pregnant patients or those who were not able to move fully independently were assessed to determine if they were suitable to undergo scan procedures.

Patients told us they underwent initial assessments and staff discussed and explained key risks to them prior to commencing their scan procedure.

Staff did not routinely carry out vital observations or assessments during scan procedures due to the short length of time taken to complete scans. However, the radiographers and sonographers told us they continuously observed and communicated with patients during their scan. Staff told us they would pause the scan if a patient’s health deteriorated or they required any intervention or support, such as if they felt anxiety or discomfort.

Staff confirmed the patient’s identity prior to commencing scan procedures. Staff also followed local safety standards for invasive procedures (LocSSIPs) and completed modified World Health Organisation (WHO) safety checklists when carrying out certain invasive procedures, such as ultrasound-supported fine needle aspiration (FNA).

The patient records we looked at showed WHO safety checklists were completed correctly. Staff carried out routine local safety standards and surgical safety audits. Audit results showed 100% compliance had been achieved during the 12 months prior to our inspection, demonstrating good staff compliance with local safety standards.

There were clear processes in place to escalate unexpected or significant findings identified during scans. Where any concerns or anomalies were identified, staff told the reporting consultant radiologist promptly notified the referring clinician or responsible clinical team.

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.

All the areas we inspected were well maintained, free from clutter and suitable for providing safe care and treatment. There was sufficient space for storage of equipment and consumables. All areas were easily accessible, including for wheelchair access.

The diagnostic scan rooms and waiting areas were located next to the outpatient department. The service had suitable waiting areas, change areas and sufficient numbers of toilets for staff and patients, including disabled toilets.

The service had on-site radiology services (including X-ray imaging, fluoroscopy and ultrasound facilities). Magnetic resonance imaging (MRI) scans were carried out from a mobile MRI scan facility. We did not inspect the MRI equipment, facilities and staffing because this was managed by the corporate provider and not in the scope of this inspection.

The service also had mobile X-ray imaging equipment that could be used in the department or across the hospital’s surgical services if required. We identified a regulatory breach relating to the cleaning and maintenance of lead aprons and for radiology equipment used in theatres during our previous inspection in December 2018.

We found improvements had been made during this inspection. We saw mobile imaging equipment (such as C-arm mobile X-ray equipment) was suitably cleaned and maintained. Staff carried out routine daily cleaning and maintenance checks and checklists were complete and up to date. Diagnostic imaging staff used lead aprons to protect themselves and patients against radiation exposure. We saw these were appropriately cleaned and maintained by staff.

The design, maintenance and use of facilities, premises and equipment kept patients safe. The diagnostic imaging equipment and premises complied with national safety guidelines, such as those from the Medicines and Healthcare products Regulatory Agency (MHRA), IR(ME)R) requirements and Ionising Radiation Regulations (IRR) 2017. Audit results over the past 12 months showed the service achieved the provider’s 90% compliance target for MHRA (100%), IR(ME)R (93.2%) and IRR (95.2%) audits.

The service had systems and processes to safely manage risks relating to ionising radiation, in line with (IR(ME)R). Radiation safety policies, risk assessments and local rules for radiation safety were up to date and were available to staff both as a paper copy or electronically. All local rules had been signed and dated by staff as being understood. Risk assessments had been completed for all the modalities of radiation and the risk assessments addressed occupational safety to radiographers and also to patients.

The service had a radiation protection supervisor and an external radiation protection advisor. The radiation protection advisor carried out an annual review of the service and provided advice and support on risks or issues relating to the service. The most recent radiation protection advisor review was undertaken in November 2025 and highlighted good compliance with (IR(ME)R) requirements, with some minor recommendations for improvements that had been actioned and implemented by the radiation protection supervisor.

There were signs and warning lights outside controlled areas where radiation was used to make it clear when it was safe to enter. Staff wore dosimeters so that managers knew how much radiation the staff had been exposed to. There had not been any instances where national minimum radiation exposure limits had been exceeded for staff or patients in the 12 months prior to the inspection.

Patients could reach call bells and staff had access to alarms in the event of an emergency. Emergency resuscitation equipment was located nearby in the outpatient department and maintained by outpatients staff. Diagnostic imaging staff told us they could easily access emergency equipment when needed.

Staff told us equipment was readily available and any faulty equipment could be replaced promptly. Single use items and consumables were stored safely and were kept within expiry dates. Equipment was serviced by the hospital’s maintenance team under a planned preventive maintenance schedule. Staff told us they received good and timely support. All the equipment we saw was clean, well-maintained and within service and calibration dates.

The hospital had an emergency back-up power system in case of power failure. Guidance for staff in the event of a major incident was available and staff were aware of how to access this information when needed. Health and safety, fire safety and control of substances hazardous to health (COSHH) risk assessments were in place and up to date. There were suitable arrangements in place for fire safety, including clear instructions for staff to follow in the event of a fire.

We scored the service as 2. The evidence showed some shortfalls. The service had enough staff to provide care that met people’s individual needs. However, the service did not consistently ensure that all staff, particularly consultants with practising privileges and bank staff, were up to date with mandatory training requirements.

Consultant radiologists completed mandatory training in their substantive employment and were required to submit evidence of mandatory training compliance annually as part of the hospital’s practicing privileges process.

Consultant radiologist training compliance for specific training topics, such as life support, safeguarding adults and children (level 1 and 2) and disability and autism training was 77.8%. However, the service reported the overall mandatory training compliance for consultant radiologists was 60.8% and below the 95% compliance target.

Radiology staff were required to complete mandatory training relevant for their role. This was delivered face to face or through e-learning training and updated either annually or every 3 years depending on the training module.

Records showed most substantive radiology staff had completed core mandatory training (94.4%) and mandatory e-learning (95.3%) and compliance was in line with or close to the provider’s compliance target of 95%.

The imaging manager told us mandatory training was regularly monitored and individual staff with outstanding training had been booked on training sessions to complete their training.

The overall mandatory training compliance for radiology bank staff was 62% and below the 95% compliance target. The service reported that changes to commissioning agreements had led to a reduction in activity since November 2025, which meant some bank staff were not utilised by the service. Planned activity was expected to recover during April and May 2026 and there was a plan in place for bank staff that had not been used regularly to complete their mandatory training before commencing any shifts.

All the radiographers and sonographers held up to date registrations with the Health and Care Professions Council (HCPC). The consultant radiologists had up to date general medical council (GMC) registrations and revalidations and were also listed on GMC specialty registers. All radiology staff and consultant radiologists had up to date disclosure and barring service (DBS) checks.

The service had enough staff to keep patients safe. The imaging manager led the service. The substantive staff consisted of 5 radiographers, 2 healthcare assistants and 2 administrative staff that worked varying shift patterns. They were supported by 8 additional bank (temporary contracted) radiographers and 2 bank sonographers, who provided additional support including during busy periods or during sickness or leave absence. The bank radiographers and sonographers were required to complete the same level of induction, training and appraisal as the substantive staff.

The service also had 11 consultant radiologists, who all worked under practicing privileges.

All scan procedures were scheduled in advance, enabling managers to plan and adjust staffing resources in advance according to patient’s needs. There were at least 3 radiographers, 1 healthcare assistant and 1 administrative staff on site during weekdays and at least 1 radiographer or sonographer and a healthcare assistant on weekends when scan procedures were scheduled.

The imaging manager told us they did not have any staff vacancies but planned to recruit an additional bank healthcare assistant to support the team. The service did not routinely use agency staff. The rolling 12-month average staff turnover rate was low (1.5%) but the average staff sickness rate was high (16%). The imaging manager told us this included individuals on long-term sick leave and the existing staff and bank staff were able to cover shifts when needed.

Staff told us they received annual appraisals. All eligible radiology staff and consultant radiologists working under practising privileges had completed their annual appraisals within the 12 months prior to the inspection. Records showed all the radiographers, sonographers and administrative staff had completed induction training and competency-based assessments relevant to their roles and these were up to date.

Patients told us there were enough staff at the service. They spoke positively about the way staff interacted with them and told us staff were kind, helpful and responsive to their needs. Staff told us there were enough staff and their workload was manageable. They were positive about on-the-job learning and development opportunities and told us they received good support from managers.

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

The diagnostic imaging services did not store any controlled drugs. The medicines kept in the department were used for routine scans and procedures (such as contrast materials used for scans). Staff also kept routine medicines for ultrasound procedures, such as local anaesthetics and muscle cramp medicines.

Medicines and contrast materials were securely stored in locked cabinets in the areas we inspected. Staff carried out routine checks on medicine stocks and expiry dates. We looked at a sample of medicines and found these were kept within their expiry dates.

The diagnostic imaging service was supported by a pharmacist and pharmacy technician during normal hours on weekdays. The pharmacy team also provided on-call cover during weekends and out of hours service. Staff told us they received good support from the pharmacy team.

Staff completed temperature monitoring of areas used for storage of medicines (including storage rooms and medicine fridges). Temperatures were monitored daily and log sheets showed these were within acceptable temperature ranges.

The pharmacist carried out a monthly medicines fridge temperature audit. Audit results between December 2025 and February 2026 showed the service achieved high levels of compliance (ranging between 98% and 100%). Staff understood how to notify the maintenance or pharmacy teams where medicine fridge or storage room temperatures exceeded maximum temperature ranges.

Staff completed mandatory medicines management training and followed the provider’s medicines management policies. Patients undergoing ultrasound scan procedures told us they received timely local anaesthetic where required and they did not have any concerns around medicines management.

The patient records we looked at showed they were given their medicines in a timely way, as prescribed, and records were completed appropriately, including allergy status.

The pharmacy team carried out routine safe and secure medicines audits every 3 months. Audit results for the 12 months prior to the inspection showed good levels of compliance (ranging between 92.6% and 100%) and action plans were in place to improve areas of non-compliance.