Practice Plus Group Hospital - Emersons Green

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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

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.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Quality Statement Score: Your judgement of the quality and safety of the topic area

3. 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.

Safety performance over time was good. Managers monitored the number of incidents across all locations and services and held monthly incident meetings to identify themes and trends and acted where necessary. Incidents of significant or unintended exposure (SAUE) to radiation were reported externally and fully investigated with clear actions. In the 12 months prior to our assessment there had been 2 SAUE incidents. The incidents we reviewed varied in type and severity, indicating a proactive and positive reporting culture. Incidents and learning were shared across all locations. For example, managers had identified trends around wrong detector selection at both Emerson’s green and its sister hospital site. We saw evidence staff involved in these incidents had received support to improve practice. The detector is a piece of equipment which is selected depending on what is being imaged. This means an image could be taken but not captured and the patient still receives the associated dose of radiation.

Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses. Staff felt empowered and trusted to raise safety concerns or propose improvements. All relevant staff, services, partner organisations and people who used services were involved in reviews and investigations. There had been 16 reported incidents in the past 12 months, which had been investigated, actions taken and learning shared.

Teams worked together to identify and share learning including dose optimisation. The service had effective arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations and reviews. The imaging service ensured unintended exposures were notified to relevant regulatory bodies. At the time of our assessment there had been no reportable incidents reportable to CQC in the 12 months leading up to our assessment.

Leaders and staff strived for continuous learning, improvement and innovation. The provider participated in the Quality Standards for Imaging and was working towards re-accreditation. Staff regularly worked together to resolve problems which led to improvements and better working relationships, both internally and with external partners.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Quality Statement Score: Your judgement of the quality and safety of the topic area

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always work well to maintain safe systems of care. Whilst they monitored and managed people’s safety, they did not always make sure all the relevant safety roles were established in the service in a timely way. 

The service did not have an onsite, qualified Radiation Protection Supervisors (RPS) in the departments which used ionising radiation. However, the radiology services manager had undertaken training but was yet to have their certificate signed off. In the interim, an RPS from the hospital’s sister site was available remotely for advice. Following our onsite assessment, the radiology services manager has now been signed off and appointed as onsite RPS. 

The service carried out comprehensive risk assessments for people who used services and staff identified and responded appropriately to changing risks to people. There were procedures for the collapse of a patient on the mobile MRI scanner, and staff were clear on the process for safely evacuating a patient with the MRI safe trolley and lift accessible from the control room.

All clinical staff received training in basic life support (BLS) and had access to onsite Advanced Life Support (ALS) trained doctors and nurses. Data provided showed between 100% compliance for BLS training for allied healthcare professionals, against a 95% target.

The service had a policy for managing deteriorating patients, which staff followed. Staff joined calls every morning at 10am, where the resuscitation team for the day was introduced. Staff used a combination of emergency buzzers and mobile radios to call for help in an emergency.

Staff followed processes to ensure the right person got the right radiological scan at the right time. Audits from January to April 2026 showed 100% compliance.

The service followed the Royal College of Radiologists standards for the communication of radiological reports and fail-safe alert notifications.

The service ensured the radiation protection advisor (RPA) and the medical physics expert (MPE) were remotely accessible for providing radiation protection advice.

Staff identified patient risks using local policies which were in line with national standards and guidelines.

The service had clear local rules (Ionising Radiation Regulations) and employer’s procedures (Ionising Radiation (Medical Exposures) Regulations) which protected staff and patients from ionising radiation. However, some polices were out of date and were missing some information such as the name of the current RPA.

Staff followed national protocols to check and ensure requests for imaging procedures were appropriate for the patient. Where there were multiple IT systems, the service ensured information was shared and accessed securely when required.

The service ensured imaging requests were appropriate and included the relevant information to allow for requests to be justified in accordance with IR(ME)R. All requests were justified by a radiographer or radiologist. Protocols for each request were recorded and details shared with radiographers.

The service ensured the ‘requesting’ of an X-ray or other radiation diagnostic test, was only made by staff / persons in accordance with IR(ME)R. The service held a list of approved referrers, both medical and non-medical. 

Most patients were provided with leaflets of ongoing advice after their procedure in a format they could understand, including easy read for children. However, patients who underwent CT scans with contrast did not receive any written information in advance of their scan, although information was communicated verbally by pre scan call made by the admin team. Following our assessment, evidence was submitted which showed patient received on the day, written information from the company providing the scan. 

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Quality Statement Score: Your judgement of the quality and safety of the topic area

3. 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 safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

The service shared safeguarding concerns quickly and appropriately. Staff employed by the service received safeguarding training at the correct level for their roles and could identify when to report abuse and how. There was clear oversight of all safeguarding incidents reported, and actions were recorded which included learning and outcomes of the incident. Staff confirmed this was shared with them through regular staff meetings and updates.

All staff had undertaken level 3 training in both adults and child safeguarding but had access to level 4 and higher trained staff through a specialist safeguarding team. Training compliance showed 100% for adult safeguarding level 3 and 100% for child safeguarding level 3. Staff knew how to raise safeguarding concerns. Staff could give examples of concerns they had raised.

Information regarding safeguarding from abuse, sexual safety and domestic abuse was displayed where service users could see it. Staff were able to access a named or designated professional for advice 24 hours a day, although the service only operated 8am-8pm seven days a week.

The service had a chaperone policy for all patients which staff understood. Patients were aware of the policy and those attending for ultrasound scans had been offered a chaperone. Wherever possible, the service tried to accommodate patient wishes when booking ultrasounds involving internal scans.

Staff had received training in Deprivation of Liberty Safeguards (DoLS) as part of their dementia training. DoLS is a legal framework within the Mental Capacity Act 2005 in the UK. It was aimed to help protect vulnerable individuals who lack the mental capacity to consent to care or treatment arrangements which may restrict their liberty. Staff gave examples of where patient with early stages of dementia had attended. Data submitted showed 100 % of staff had completed this training as part of their mental capacity training.

Staff understood the principles of Gillick competence and described how if they had to ask about pregnancy, patients under the age of 18 were given the opportunity to answer away from their parent or guardian.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Quality Statement Score: Your judgement of the quality and safety of the topic area

3. 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 carried out comprehensive environmental risk assessments for people who used services, and these were reviewed every 2 years or more frequently if risks changed. Staff had access to all relevant risk assessments in an online database.

The service had local rules (Ionising Radiation Regulations) and employer’s procedures (Ionising Radiation Medical Exposures Regulations) which protected staff and patients from ionising radiation. Staff told us they were trained in radiation safety, and training data supplied showed 100% compliance.

The service had policies for the risk assessment and prevention of contrast-induced nephropathy (damage). These followed National Institute for Health and care Excellence (NICE) Acute kidney injury guidelines and the Royal College of Radiologists standards for intravascular contrast agent administration. Contrast is a type of dye used in some scans to make blood vessels clearer. CT examinations were undertaken by a third-party provider who distributed post scan information around allergies.

The imaging service ensured people who were, or may be pregnant, always informed a member of staff before they were exposed to any radiation. Audit data showed 100% compliance between January 2026 and April 2026.

Inclusive pregnancy checks were undertaken, recorded and audited as part of the annual IR(ME)R audit programme. 

Staff enabled patients to give feedback on the service they received. Patients we spoke with said they felt supported by staff. We saw evidence patient choice was respected when deciding which treatment option to choose.

Staff followed protocols if a patient's health deteriorated. They called 999 for an ambulance and clinical staff were able to provide support until the ambulance arrived.

A resuscitation trolley was easily accessible to staff in the event of an emergency, which was in the endoscopy department. The trolley was fully equipped in line with best practice guidance and checked regularly.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Quality Statement Score: Your judgement of the quality and safety of the topic area

3. 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 and premises kept people safe. The imaging service ensured non-ionising and ionising radiation had arrangements to control the areas and restrict access.

Equipment was maintained and serviced in line with manufacturer guidance or whenever issues arose. The provider had an equipment quality assurance programme and were carrying this out on all X-ray, CT and ultrasound equipment.

Resuscitation equipment was readily available for both adults and children and staff checked it regularly.

Staff and carers used personal protective equipment when needed. Lead aprons and lead screens were checked annually for their integrity.

Arrangements for managing waste and clinical specimens kept people safe.

The imaging service undertook risk assessments for all new or modified uses of radiation, which took account of occupational safety as well as considering risks to people who used services. All assessments we reviewed were in date of review.

The provider undertook assessments and reviews of their activities under the Control of Substances Hazardous to Health Regulations 2002 (COSHH).

Engineering support was supplied through formal maintenance contracts and overseen by an in-house, central, team. Maintenance of the scanners could be planned, and issues or breakdowns were responded to promptly. The third-party contract performance was monitored by the operations manager and fed into the overall clinical governance meetings.

The service monitored staff for radiation exposure and staff told us they saw their dose reports.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

Quality Statement Score: Your judgement of the quality and safety of the topic area

3. 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.

Staff had regular appraisals and one to one conversation with their managers. Data submitted showed 100% of staff across all staff roles had received a performance review.

Staffing levels and skill mix were planned and reviewed so people always received safe care and treatment, and staff did not work excessive hours. Actual staffing levels and skill mix compared well with the planned levels and cover was provided for staff absence.

Arrangements for handovers and shift changes ensured people were safe and allowed time for staff to plan, complete equipment checks and obtained any additional information required to perform safe scans, such as blood test results for CT contrast scans.

There were enough radiologists and radiographers to meet the demands of the service. Radiologists were available to provide advice each day. The service had 1 full-time radiologist, but another was available at the hospital’s sister site.

Services ensured relevant staff continued registration with relevant bodies and gave support with revalidation where necessary.

Staff who were undergoing training, such as student radiographers, were adequately supervised in accordance with legislation set out under IR(ME)R.

Staff received training to make them aware of the potential needs of people with mental health, learning disability, autism or dementia needs. Training records showed staff compliance was 100% for awareness of dementia and autism.

Staff were given time to undertake mandatory training. Overall mandatory training compliance was 100% across all staff groups against a 95% target. Where training compliance was below this target, the service had clear oversight of barriers and had taken steps to address the gaps.

Managers monitored sickness rates and in the 12 months prior to our assessment, data showed 1.89% to 2.59% sickness rate in the radiology department.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Quality Statement Score: Your judgement of the quality and safety of the topic area

3. 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.

Staff took precautions when seeing people with suspected communicable diseases. Where possible, booking staff obtained as much relevant information about a patient before they attended for their scan. In the event of a patient attending with an infectious disease, staff arranged for additional cleaning to be undertaken. If a patient was vulnerable to infection, patients were booked towards ends of lists to minimise contact with other patients.

The service maintained high standards of cleanliness and hygiene through comprehensive infection training and staff awareness. The service had reliable systems to prevent and protect people from a healthcare-associated infection. Data showed 100% compliance for infection control training for all staff roles.

Staff had access to personal protective equipment should they require it. Audits showed good staff compliance with hygiene processes including hand hygiene, and cleaning logs had no omissions. Staff we saw were all bare below the elbow and compliant with the service’s infection, prevention and control policy. We saw staff decontaminating their hands in between patient contacts.

The service had cleaning procedures for ultrasound probes using a recognised 2 step cleaning system but was moving to a 3-step system following an alert from NHS England around transvaginal probe decontamination. Serial numbers of internal probes used were not recorded against each patient, however, there was only one probe in the department at the time of our assessment. In the event of an issue with the TV probe, and a temporary replacement was provided, the service would update the equipment log to allow full traceability.  

Staff were provided with clean uniform and were familiar with the uniform policy around covering uniform when travelling to and from work.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Quality Statement Score: Your judgement of the quality and safety of the topic area.

3. 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 involve people in planning, including when changes happen.

Staff followed the services processes for medicine administration. Medicines were ordered, transported, stored and disposed of safely and securely, including contrast agents and oxygen cylinders.

Staff carried out comprehensive allergy and safety checks before all scans, including those involving contrast medium. This information was stored on the radiology computer system and a warning flag alerted staff to previous allergies. The service did not provide patients with written information in advance of their scans, however, information was provided by the company providing the scan, when the patient attended their appointment. 

Staff used Patient Specific Directions for each scan which involved intra-venous contrast. We saw radiologists record this on the electronic system of the type, strength, amount and flow rate of contrast required for each scan.

Radiopharmaceuticals, contrast media and other medicines were stored correctly and in line with manufacturer guidance. 

Saline and medicines (such as lidocaine) used for ultrasound guided shoulder injections all had Patient Group Directions (PGD), which were in date and signed by all relevant staff. A PGD is a written instruction that allows registered staff to administer a specific medicine to a pre-defined group of patients without the need for a prescription of doctor consultation.