Oaklands 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 looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

The service had effective systems of assessing and managing patients throughout their journey to ensure that risks were appropriately considered and that urgent findings were managed in a timely way. Areas were clean and well-maintained with effective audit processes to ensure issues were identified and actioned quickly.

However, the service had not always sufficiently assessed security arrangements in all areas, and staff safeguarding training levels were below typical targets.

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.

In the 12 months before the assessment, the radiology service at the location had recorded 10 incidents, which was less than in the outpatients and endoscopy services. Incidents were reported through an electronic system and raised for the attention of the service lead, who reviewed the details and determined actions or escalations as appropriate. Incidents were responded to and closed in a timely way.

Staff demonstrated a good understanding of what incidents should be reported and told us they felt confident in doing so. Incident reports advised staff of when the duty of candour applied as part of the Patient Safety Incident Response Framework (PSIRF) and when external notification processes were required. The electronic system also allowed the manager to visualise what actions relating to each incident were still outstanding, which improved their oversight and ensured that changes were implemented appropriately.

Possible emerging risks or key findings from other hospitals in the provider network were also shared with the service routinely through “safety flashes”. We saw that these were displayed in staff areas and discussed at staff meetings to ensure the service could work proactively to prevent these occurrences.

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 accepted referrals from various sources and had clear processes in place to manage these. Clinical staff spent part of their working time dedicated to reviewing and managing referrals and they followed clear exclusion criteria in doing so. For example, staff would routinely ensure patients referred for MRI scans did not have any unsafe implantable devices prior to accepting the referral. The service did not accept patients under 18 years of age.

The service used a Picture Archiving and Communication System (PACS) that stored and retained images in keeping with guidelines. Connectivity between the mobile MRI van and central PACS systems had been a previous issue at the location. The service had responded appropriately with the use of back-up discs for image storage and then had uploaded these separately, when connectivity was not possible. There had been no incidents reported related to loss of patient data or patients requiring further scans because of this problem.

Reporting responsibilities were managed by the provider and not contracted elsewhere. Staff ensured that, once reported, scan results were sent to the referring location promptly for their action. The service had also recently introduced a communication tool that enabled reporting radiologists to automatically notify the referrer of any findings that were clinically significant and needed a more urgent response. This helped ensure these findings were reviewed and actioned by allowing the results to be acknowledged by the referrer.

We scored the service as 2. The evidence showed some shortfalls. While the service had suitable safeguarding policies and procedures that aligned with the needs of their patients, the service could not demonstrate sufficient compliance with safeguarding training.

We spoke with radiographers and support staff who demonstrated a good understanding of their responsibilities and were able to give examples of how they could identify and help protect vulnerable adults and children at risk of harm.

Policies were in place that clearly communicated what level of safeguarding training was required to be undertaken by each staff group in radiology. Staff also took part in mandatory dementia awareness, modern slavery and Prevent (safeguarding from the threat of radicalisation) e-learning modules. However, compliance with safeguarding training, which included mental capacity training, was below typical targets for staff in radiology at the location, at 70%. This meant the service could not be assured that all staff were sufficiently familiar with safeguarding processes to be able to identify and action concerns.

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.

We observed activity where staff clearly communicated with patients about the risks and benefits of the procedures, in a way that was easy for them to understand. Patients confirmed they always felt fully informed about the procedure beforehand and had opportunities to ask questions or address any concerns. Staff were experienced in handling patient anxieties, and we observed them use strategies to help manage this during procedures.

The service had clear procedures and documentation to ensure that risks were fully considered and consented for in advance. This included safety screening checklists that included pregnancy status declarations, and consent forms specific to various imaging scenarios such as for CT/MRI scans with contrast, when patients lacked capacity to give informed consent, or when patients had tattoos or unremovable piercings.

We scored the service as 2. The evidence showed some shortfalls. The service had good oversight of equipment and radiation protection requirements. However, it did not always detect and control potential risks in the care environment.

The radiology area at the location was on the first floor, accessible via stairs and lift. The area was identifiable by signs and had a reception desk where patients could check in. Parking, signage and facilities were mostly sufficient for patients with a variety of needs, and all areas and clinic rooms were tidy and pleasant environments throughout, with up-to-date cleaning checklists.

Not all rooms had fully considered arrangements to protect the security and wellbeing of staff. While the fixed X-ray room had multiple routes of egress and the ultrasound room was typically used by 2 staff working together, the DEXA scanner room situated staff working alone in between the patient and the door and in a small space, with no panic alarm or other security procedures in place. We advised leaders of this during the assessment and they told us they would review working arrangements in the DEXA scanner room with an aim to improve this.

However, the service had good oversight of the equipment they were responsible for, which was all serviced and calibrated within the necessary time frame. Local rules were accessible in each X-ray room and were effective. In line with local rules, radiation protection supervisors (RPSs) were in place who undertook regular radiation safety audits. A radiation protection advisor (RPA) was also contracted and had undertaken an annual audit, with no significant concerns identified. Staff wore personal dosimeters (radiation level meters) that ensured they were not being overexposed to ionising radiation. Environmental monitoring with dosimeters was also routinely undertaken, and personal protective equipment (PPE) was in good condition and underwent documented checks routinely.

Fire safety arrangements were regularly considered at health and safety meetings, and an annual fire safety audit took place, which included actions that had been documented and completed appropriately. Substances that met Control of Substances Hazardous to Health (COSHH) regulations were all stored appropriately in a locked cabinet. A resuscitation trolley and automated external defibrillator (AED) were available close to the radiology area, and this was checked routinely by staff. Staff demonstrated a good awareness of where this could be located at short notice.

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 radiography and support staff to keep patients safe and manage demand, and the manager could review the planned activity and adapt staffing levels where needed with the use of agency or bank staff, for example in cases of unplanned absences. The service had no current open vacancies and staff turnover was within expected levels.

The provider had an effective recruitment policy that outlined other typical pre-employment processes such as Disclosure and Barring Service (DBS), qualifications checks and health assessments including vaccination status. Radiographers in the service were all registered appropriately with the Health and Care Professions Council (HCPC). Consultant doctors worked under practicing privileges arrangements and a sample of recruitment records we reviewed demonstrated appropriate pre-employment and training checks were undertaken for these staff. The provider also had policies regarding the management of performance concerns amongst both substantive and agency staff.

Staff we spoke with said their induction was a positive and supportive experience, and that this included meeting staff, touring the hospital and an introduction to the provider’s corporate policies and procedures.

While the suite of mandatory training required for staff was comprehensive and met the needs of radiology patients and staff, overall face-to-face mandatory training compliance was slightly below typical provider targets, at 82%. The worst performing module was fire safety, with a compliance of 63%. However, some modules such as radiation safety and immediate life support (ILS) had a 100% compliance.

All staff in the radiology department had an appraisal (or performance development review, PDR) dated within the last 12 months. We saw recent examples of PDRs that included constructive reflections and objective-setting, including plans which supported further training and development opportunities. For example, the hospital had developed a system where staff as part of their PDR were permitted to spend time and observe other areas of the hospital to improve their exposure and understanding of different work areas. Staff told us that this had been beneficial for them and improved relationships between areas and that the PDR process was a useful experience for them.

Staff also had access to additional training and competencies beyond mandatory modules, which included venepuncture/cannulation training, chaperone competence and use of the on-site disinfection equipment. Some staff had also obtained certification in the use of bone densitometry to support their competence in DEXA imaging.

We scored the service as 3. The evidence showed a good standard. The service detected, assessed and controlled the risk of infection appropriately.

All clinical and patient areas were visibly clean and well-maintained. Clinic rooms and toilets had appropriate handwashing facilities and checklists which demonstrated that staff cleaning had been undertaken consistently. We saw staff follow appropriate hand-hygiene procedures, uniform policies and “bare below the elbow” guidance.

The service routinely underwent a comprehensive audit to identify and action any concerns with the cleanliness of the environment. This included the condition and cleanliness of all shared-use personal protective equipment (PPE) for radiation safety, and the appropriate management of clinical and medicines waste. All recent audits had demonstrated consistently good compliance. There were provider-level policies for managing and isolating patients with infectious disease, although this was a very rare occurrence in the service as most clinical activity took place as outpatient attendances or on short-stay post-operative patients.

The service had developed processes for managing the effective cleaning and disinfection of ultrasound probes between uses in keeping with guidance, which included the use of new equipment to automate the disinfection process following higher-risk procedures such as internal pelvic scans. Several key staff had recently undergone training in the effective use of this equipment to support consultant-led sonography activity.

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 happen.

Medicines stored and managed in the radiology area consisted of various contrast agents for use in MRI, CT and arthrogram procedures. These were stored in a secure cupboard where the temperature was routinely recorded to ensure the contents were stored in accordance with product directions. Access to the cupboard was controlled with keys that were themselves secured in a key safe in a separate staff area.

Staff were compliant with medicines management e-learning training and we observed clinical episodes where medicines were checked for assurance between staff prior to administration, in line with best practice.

The service had a policy for ensuring and recording the safe access and storage of medicines for use in the mobile scanner units that visited the site regularly. These worked effectively to ensure that excess medicines were not taken and kept on the units unnecessarily.

However, prescriptions were not always filled out in accordance with best-practice guidelines. We found a prescription pad kept in a secure area that had been pre-signed across multiple pages without any further details added, although it was only possible to prescribe a limited number of medications using these forms. When we advised leaders of this, they told us that this was not common practice and they would speak to the prescriber to ensure this did not happen again.