Rivers 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 safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

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. 

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 provided mandatory training to all staff, and completion was monitored by leaders.  

Access was given to an e-learning training package that included mandatory modules such as health and safety, safeguarding, General Data Protection Regulations (GDPR), and radiation protection. During the inspection, it was confirmed that all employed radiographers were up to date with all required training.   

Staff understood how to recognise incidents and near misses and how they should be reported. Leaders understood how to investigate incidents and shared lessons learned with the team and wider service. Leaders told us learning was shared during team meetings. Staff knew what incidents required reporting and how to report them.  

Staff understood that when things went wrong, apologies should be given, along with honest information and suitable support. We observed staff were aware of Duty of Candour and staff understood apologies should be given where needed. Duty of Candour is a legal obligation to be honest about when things go wrong in a person’s care. Leaders understood incidents should be investigated and when regulatory bodies should be notified of incidents. Staff and leaders told us what the process for Duty of Candour is and were able to explain when Duty of Candour may be needed.  

Leaders told us there had been 1 incident in the last 12 months where a patient had a reaction to a contrast substance. Staff told us the process for incident reporting and explained learning was shared after these incidents when investigations were completed.  

The lead radiographer managed complaints.  

Although no imaging-related complaints had been received, staff told us that should complaints be made, these would be discussed and shared for learning and improvement.  

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 provided private services. Most patients were referred by a private consultant but the service also saw patients who were referred by an NHS provider. Leaders told us the team shared information with the GP through secure email for NHS patients. Staff told us patients received a summary of care after their treatment.  

Staff told us they may need to communicate with other departments in the hospital. In the event a patient needed to be referred to another department, there were referral forms for the different pathways. Staff told us communication between departments works efficiently and referrals are simple processes. If there are any issues or concerns, a conversation would take place with professionals from the relevant departments.  

Staff and leaders told us that if patients needed urgent care and treatment, they would be transferred to an NHS provider. Information and imaging would be shared by email for patients who required ongoing care.   

The Society of Radiographers’ “Pause and Check” process was used by the service. This initiative was applied to remind radiology staff to confirm they had the correct patient, the correct body part for imaging, and that all user settings were correct for the investigation.    

Staff were trained in current Ionising Radiation Medical Exposure Regulations (IRMER) guidance, and recent training certificates for staff members were seen after the inspection.   

The lead radiographer told us there is a Radiation Protection Advisor (RPA) and Radiation Protection Supervisor (RPS) and showed us a recent email in which the lead radiographer had advised they would be forwarding a recent audit. We found contact details for the RPS and RPA are easily available.  

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 harm. Training on how abuse could be recognised and reported was provided. Staff we spoke to felt confident in recognising all types of abuse. Staff knew who to report safeguarding concerns to. Staff told us the service had a safeguarding lead they could approach for safeguarding concerns. The service had a designated trained safeguarding lead who had oversight of safeguarding concerns.   

We saw Safeguarding Adults and Children level three training certificates. This was confirmed as being in line with the Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff Intercollegiate Document (January 2019), which sets competency requirements for clinical staff in contact with children.  

We saw evidence of safeguarding training certificates and a safeguarding adults policy was in place and was in date. We also saw evidence all staff had completed Mental Capacity Act and Deprivation of Liberty Safeguards training.  

There had been 1 safeguarding concern raised in the last 6 months. We saw evidence these were appropriately investigated.  

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.

Staff were aware they escalate concerns to the lead radiographer or head of department. Staff said they felt confident concerns would be investigated. Staff told us they felt very supported by the head of department. Staff were aware of the risks of diagnostic imaging such as radiation exposure. Staff told us they were aware of risks for patients with mobility issues and additional supports and aids were in place.   

The service had systems in place to manage risks to pregnant women. Within the department, posters were displayed for staff reference.   

Exposure doses used for each patient were documented by staff, and backups of each image were made. X-ray images were saved to the Picture Archiving and Communication System (PACS).  

Risk assessments were completed for each patient at each appointment, and they were updated when necessary. For example, female patients were risk assessed for pregnancy status. Images taken by radiographers were interpreted by the referring clinicians. Responsibility for interpreting images was held by referring clinicians, who had a process in place for escalating unexpected or significant findings.  

There had been 0 unplanned or urgent patient transfers in the last 6 months. Staff and leaders told us that, in the event of a medical emergency, the patient would be sent to hospital via the regional ambulance service.  

An ‘X-ray questionnaire for female patients’ was completed by female patients with the radiographer. This established any possibility of pregnancy, as well as menstrual cycle and menopause information where appropriate.   

Patients’ names, dates of birth and, where relevant, female questionnaire answers were double checked by radiographers before diagnostic imaging procedures were conducted. 

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 environment and facilities were well-maintained and accessible to patients and relatives. Patients had access to toilets, changing room. Staff told us they ensured patients were involved in their care by letting them have a voice. Patients with reduced mobility and those using pushchairs. Each room in the diagnostic imaging department was lockable and was equipped with appropriate signage when in use. Fire exit signs were displayed, and two points of entry and exit to the building were provided.   

Equipment was cleaned after each patient contact, and labels were applied to show when it was last cleaned. We observed staff cleaning equipment after use. The department had an infection control lead for the service. Infection control guideline was in place.  

During our inspection, we observed emergency resuscitation equipment in areas that were easy for staff to access in the event of an emergency. There had been 1 incident in the last 12 months of a patient who needed resuscitation. Staff told us there were concerns whether this incident was responded to appropriately. Leaders told us an incident investigation had been completed and lessons learned were appropriately shared. Staff we spoke to said they felt the incident was investigated well and they felt leaders acted appropriately to make sure a similar incident didn’t happen again.  

All diagnostic imaging equipment was maintained, serviced and kept safe in line with national guidance.  

The service had a health and safety policy statement that was in date and accessible to staff. The statement set out roles and responsibilities relating to environmental risk assessments.   

Staff we spoke to on the day of the inspection had current training and knowledge of the radiation medical exposure regulations (IRMER) guidance. This meant that radiology referrals could be assessed by staff to confirm they were in accordance with IRMER guidelines.  

The service had a designated radiation protection supervisor (RPS) who was up to date with training competences.   

The necessary radiation safety signage was seen. The sign advised that X-rays were in progress and that access to the room was not permitted.   

We observed patient records stored securely. The service used an electronic database for storing patient records. Completed radiology request forms were stored within patient records. There were hard copies available on site for the day the patient came in but these would be saved onto the electronic database. Records of returning patients were stored on an electronic system.  

The service had updated equipment risk assessments and audits. Required certificates for radiation use were in date and Ionising Radiation Medical Exposure Regulations (IRMER) were also in date.   

We saw dated risk assessments during our inspection. Risk assessments and audits were dated from 2025. We observed leaders were in the process of updating audits within the timeframe they had been advised by the Radiation Protection Advisor (RPA). The service had a named RPA for radiation and IRMER documents had appropriate review dates.  

The technological components of radiology were managed by medical physicists. Radiation protection advice was provided by a Radiation Protection Adviser (RPA) with the necessary experience and expertise for organisations using ionising radiation. Records of this were seen on the day of the inspection showing advice provided by the RPA regarding dosage levels. 

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.

Staffing was planned in line with the number of patients booked to use the service. The service employed 13 permanent radiographers cross general and cross sectioning imaging, with 1 senior radiographer responsible for leading audit work and the running of general facility. No current vacancies were held by the service at the time of inspection. Staffing levels and skill mix were regularly reviewed and adjusted by managers. 

Clinic lists were reviewed weekly. Leaders told us they used a staffing tool and demand and clinic capacity was monitored to determine how many staff were required to safely run the service. There were no waiting times for patients and clinics had not been cancelled due to lack of staff in the last 12 months.   

No sickness had been recorded in the 3 months prior to inspection.  

Radiographers were required to maintain registration with the Health and Care Professions Council (HCPC), and in date.  If a patient required basic life support, a clinician who was up to date with cardiopulmonary resuscitation training would be called. Staff and leaders told us they knew which nursing or doctor colleagues were appropriately trained to do this and how they would contact them in the event of an emergency. Treatment rooms were located across two floors. Emergency resuscitation equipment was available on both floors.   

Training needs were identified by managers, who gave staff opportunities to develop skills and knowledge. Radiography staff were supported to complete role specific courses; for example, both radiographers had completed updated IRMER training. Continuing professional development was maintained by radiographers through reading journals, attending courses, and, for the lead radiographer, participating in external research.  

Staff told us clinicians offered training for free to all staff. This was observed as good practice and encouraged upskilling.  

Yearly work performance was appraised by managers, and supervision meetings were held to provide support and development. Staff told us they found this useful and that leaders ensured radiographers worked across the modalities in order to ensure professional development.  

Staff explained the process for situations of staffing shortages. Staff told us if there are any staff absences then staff from local hospitals may be called. Staff and leaders told us if staffing levels were not deemed safe then the appointments for the day would be cancelled.

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.

Infection risks were controlled by the service to protect patients, staff and others from infection. Equipment and premises were visibly clean. The service had an infection prevention control lead. We saw evidence of cleaning audits undertaken by the housekeeping team.  

We observed staff following infection prevention and control principles, including handwashing and the correct use of personal protective equipment (PPE).  

Anti-bacterial soap and alcohol hand sanitiser were available in multiple areas, and handwashing facilities were accessible to staff.  

Staff working in clinical areas were bare below their elbows to allow for full hand decontamination. Leaders told us they completed audits to assess cleanliness. We saw evidence of these audits that showed staff complied with hand hygiene. We observed staff following hand hygiene practices on the day. Equipment was wiped clean by radiographers after each patient contact.  

The service reported 0 cases of healthcare-associated infections (HCAI) in the reporting period prior to the inspection. These infections are defined as those acquired in a healthcare setting that the patient did not have prior to attendance. 

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

Patients told us they were informed about the possible side effects, how it may make them feel and they were asked if they wanted to continue before any medicine was given to them. 

For each scanner the staff had access to required medicines and there were securely stored. Emergency medicines were kept in an accessible container. Medical oxygen cylinders were stored, staff told us these were administered under Patient Group Directions (PGDs) and Standard Operating Procedures (SOP’s). Patient Group Directions are written instructions that allow registered healthcare professionals, such as nurses, to supply and administer specific medicines to pre-defined groups of patients safely, without a doctor’s prescription. The service used systems and processes to safely prescribe, administer, record and store medicines. 

Staff completed medicines records accurately and kept them up to date. There was effective governance of medicines, for example, audits of storge and security of medicines.  

Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps to prevent recurrence if this occurred.