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Northampton Diagnostic Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 24 December 2018

The provision of PET/CT scanning services, which is classified under the diagnostic imaging and endoscopy core service was the only core service provided at this service. We rated this core service as good overall. There were systems, processes and practices essential to keep patients safe identified, put in place and communicated to staff. Care records were written and managed according to best practice.

 In most cases, relevant and current evidence-based guidance, standards, best practice and legislation was used to identify and develop how services, care and treatment were delivered.

 Information about the outcomes of patient’s care and treatment was routinely collected and monitored. There were governance frameworks to support the delivery of good quality care. 

However, we were not assured staff working with radiation had appropriate training in the regulations, radiation risks, and use of radiation.

Inspection areas

Safe

Good

Updated 24 December 2018

We rated safe as good because:

  • Staff received effective mandatory training in the safety systems, processes and practices.

  • There were systems, processes and practices essential to keep patients safe identified, put in place and communicated to staff.

  • Standards of cleanliness and hygiene were maintained.
  • The design, maintenance and use of facilities and premises prevented patients from avoidable harm.
  • There were comprehensive risk assessments carried out for patients who used services and risk management plans developed in line with national guidance.
  • There were sufficient numbers of staff with the necessary skills, experience and qualifications to meet patients’ needs.
  • Patients’ individual care records were written and managed according to best practice.
  • Arrangements were in place for managing fluorodeoxyglucose (FDG) and fluoroethylcholine (FEC) that protected patients from avoidable harm.
  • There was an effective system in place for reporting incidents. Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses.

However,

  • We were not assured staff working with radiation had appropriate training in the regulations, radiation risks, and use of radiation.
  • Staff were unable to provide evidence of training and were unaware of the Ionising Radiation Regulations 2017 (IRR17) and the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R17). They were also unable to direct us the IRR regulations.
  • While there were processes in place to ensure the right radiopharmaceutical was injected, on the day of inspection, a lone radiographer was administering fluorodeoxyglucose (FDG) to patients. There was no opportunity for a second clinician to check the dosage prior to administering.

Effective

Updated 24 December 2018

We currently do not rate effective, we found:

  • In most cases, relevant and current evidence-based guidance, standards, best practice and legislation was used to identify and develop how services, care and treatment were delivered.
  • There were no nutrition services provided by the unit for patients that attended for PET-CT scans. However, patients had access to bottled water in reception and in the waiting/treatment rooms.
  • Patients were asked by staff if they were comfortable during their appointment.
  • Information about the outcomes of patient’s care and treatment was routinely collected and monitored.
  • Staff had the right qualifications, skills, knowledge and experience to do their job when they started their employment, took on new responsibilities and on a continual basis.
  • Staff were appropriately involved in assessing, planning and delivering patient’s care and treatment.
  • The service operated on Mondays, Wednesday and Fridays.
  • Information leaflets such as understanding your PET-CT scan were sent to patients with their appointment letters and were available in the waiting rooms.
  • Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children Acts 1989 and 2004.

However,

  • We were not assured the standards of practice (SOP) available to staff on the intranet and in a folder to the office were up to date and referenced the Ionising Radiation Regulations 2017 (IRR17) and the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R17). The SOP shown to inspectors referenced the 2000 regulations.

Caring

Good

Updated 24 December 2018

We rated caring as good because:

  • Staff understood and respected patient’s personal, cultural, social and religious needs, and took these into account.
  • Staff understood the impact that a patient’s care, treatment or condition had on their wellbeing and on their relatives, both emotionally and socially
  • Staff communicated with patients to ensure that they understood their care, treatment and condition.

Responsive

Good

Updated 24 December 2018

We rated responsive as good because:

  • Information about the needs of the local population was used to inform how services were planned and delivered.
  • Patients’ individual needs were accounted for. Staff delivered care in a way that took account of the needs of different patients on the grounds of age, disability, gender, race, religion or belief and sexual orientation.
  • Patients had timely access to scanning. Since opening in August 2016, the service had worked closely with the acute trust team to improve the quality of the service provided.
  • Patients we spoke with told us they knew how to make a complaint or raise concerns about the service. Complaints were responded to in a timely way.

Well-led

Good

Updated 24 December 2018

We rated well-led as good because:

  • Leaders had the skills, knowledge, experience and integrity to manage the service.
  • The provider had a clear vision and a set of values Is there a clear vision and a set of values, with quality and safety the top priority.
  • The registered manager promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • There were governance frameworks to support the delivery of good quality care.
  • There was a risk assessment system in place locally with a process of escalation onto the corporate risk register.
  • Electronic patient records were kept secure to prevent unauthorised access to data however authorised staff demonstrated they could be easily accessed when required.
  • The service gathered patients’ views and experiences and used these to shape and improve the services and culture.

However,

  • Staff working with radiation were provided with training in the regulations, radiation risks, and use of radiation. Staff were not aware of the changes made by the introduction of the Ionising Radiation Regulations 2017 (IRR17) and the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R17) which had been introduced in February 2018.
Checks on specific services

Diagnostic imaging

Good

Updated 24 December 2018

The provision of PET-CT scanning services, which is classified under the diagnostic imaging core service was the only core service provided at this service. We rated this core service as good overall. There were systems, processes and practices essential to keep patients safe identified, put in place and communicated to staff. Care records were written and managed according to best practice. In most cases, relevant and current evidence-based guidance, standards, best practice and legislation was used to identify and develop how services, care and treatment were delivered. Information about the outcomes of patient’s care and treatment was routinely collected and monitored. There were governance frameworks to support the delivery of good quality care. However, we were not assured staff working with radiation had appropriate training in the regulations, radiation risks, and use of radiation.