Wigan PET Centre

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.

Leaders kept good oversight of safety incidents and used lessons learned to improve the service. The service had enough staff to provide safe care. Staff had completed their mandatory training and had the skills and qualifications needed to work safely. The premises and equipment were clean and well maintained. Safety risks were identified and dealt with quickly.

The service had effective procedures in place to protect people from unnecessary exposure to radiation. Radioactive materials were transported, stored, and disposed of in line with guidance. Staff made sure they had the information they needed before carrying out scans safely. Patients were given clear information about the risks and benefits of the scanning procedure.

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 managed patient safety incidents well and had a positive culture where staff felt able to report concerns. In the 12 months before the inspection, the service reported 25 incidents. Most were clinical incidents linked to medicines extravasation, which is when a medicine leaks from a vein into the surrounding tissue.

Incidents were fully investigated and assessed according to the level of risk they posed. The service recorded the actions taken, lessons learned, and any harm caused to patients. All incidents reported in the previous 12 months were recorded as low harm. Incidents were also grouped into categories so the service could identify any patterns or trends.

We reviewed 3 incidents from the previous 12 months in more detail. We saw that information about incidents was shared with staff so they could learn from them and help prevent similar incidents from happening again. Findings were also shared through governance systems so that other locations run by the provider could learn from them.

Staff knew how to identify and report risks and told us they were confident that concerns would be acted on. They understood the common causes of incidents and how risks could be reduced. Staff showed a good understanding of the duty of candour. Incident records showed how staff had explained incidents to patients at the time, so any follow-up action could be taken if needed. Staff who reported incidents were also told about the findings and actions taken, which helped them learn from the process.

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 only accepted referrals from the associated specialist NHS trust. Because all referrals came from the same organisation, they were provided in a consistent format and contained the information staff needed.

Referrals had already been reviewed as part of the trust's wider PET-CT waiting list process and did not need a separate clinical review before being accepted. However, clinicians at the service still checked referral forms for the correct signatures. They also decided which scan was needed and how long it was likely to take. The service kept a record of radiologist signatures from the trust so staff could check them if needed.

Staff could easily contact the referring trust or its booking team if they had any questions or concerns. Weekly on-call radiologist rotas were provided by the trust and displayed in the control room. The trust's booking team followed its own procedures for booking patients into the service. Up to 19 patients could be booked each day, although the number seen depended on the type and length of scans required.

The service only treated adult NHS patients and did not see private or self-paying patients. Patients with more complex needs were seen at the referring specialist NHS trust instead. There was good communication between the service and the trust to make sure patients received care in the most suitable location.

A PET-CT safety consent form was completed for every patient before their appointment. The form covered a wide range of safety checks and reminded staff to confirm patient identity at key stages of care. We reviewed a sample of completed forms and found they had been filled in correctly. After the scan, forms were uploaded to the service's IT system so reporting clinicians could review them when interpreting the images.

The service had systems and processes in place to make sure the right patient received the right procedure at the right time. We followed the patient pathway and reviewed care from arrival to discharge. Skilled and qualified staff supported patients throughout their care. Staff gave patients enough information to help them understand the procedure and checked their details at each stage.

After the scan, ongoing clinical responsibility returned to the referring specialist NHS trust. However, patients could stay at the service for longer if they needed time to rest or recuperate. Staff gave patients clear and sensitive advice after the radiotracer had been administered. This helped reduce any risk to other people. Women and birthing people who were breastfeeding were given additional advice because there were extra safety considerations for these patients. Staff also gave advice to family members and friends who had accompanied the patient about keeping a safe distance for a short period after the procedure.

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 knew when to work with other organisations to keep people safe. All staff completed mandatory safeguarding training in line with the Royal College of Nursing (RCN) 2024 Adult Safeguarding: Roles and Competencies for Health Care Staff guidance. Staff completed level 2 safeguarding training for both adults and children. The service manager had completed level 3 safeguarding training. At the time of the inspection, all staff were up to date with their safeguarding training.

The service followed provider-wide policies and procedures for safeguarding adults. These had been reviewed recently and remained effective. There was a named safeguarding lead who had received additional training and could provide advice and support when needed. The service had clear procedures and contact details for raising safeguarding concerns with partner organisations. This included access to the nearby trust's Independent Domestic and Sexual Violence Adviser (IDSVA).

Staff considered safeguarding concerns whenever an incident occurred. They sought advice or made referrals when needed. The service worked with external agencies and staff understood what would happen after they raised a concern. Staff involved in safeguarding cases were offered the opportunity to meet with the safeguarding lead. This gave them time to reflect on their practice and discuss any concerns they had.

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 worked with patients to identify and manage risks. Care and treatment were provided in a way that was safe and supportive. During the inspection, patients told us that staff listened to them, explained any risks, and involved them in decisions about their care. For example, when we observed a patient who had additional risk factors, we saw staff explain these risks clearly and sensitively and gave the patient the opportunity to ask questions.

The service used a PET-CT patient safety consent form to make sure risks were considered before each procedure. The form covered a range of areas, including childbearing potential, medical history, allergies, and any reasonable adjustments a patient might need. Both the patient and the clinician signed the form to confirm they understood and agreed the information recorded.

Before giving the radiotracer, trained staff checked the patient's height and weight and measured their blood sugar level. The service had clear procedures for managing patients whose results were outside the expected range. During the inspection, we saw a clinician seek additional advice when a result was close to the limit to make sure it was safe and appropriate to continue with the procedure.

The service monitored how risks were recorded through its regular audits of compliance with the Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER). The most recent audit showed that staff asked all relevant patients about their pregnancy status before the procedure.

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 service was based in a modular building on the site of a nearby NHS trust. There were suitable security arrangements in place to prevent unauthorised access, which included CCTV in all appropriate areas. Radiography assistants met patients on arrival and escorted them between clinical areas. This meant patients were not left unattended.

The building and clinical areas were accessible to wheelchair users. Emergency evacuation plans considered the needs of people using the service. Patient cubicles contained either a trolley or an armchair, depending on the patient's needs, and each cubicle had an accessible call bell. Corridors and shared areas were clean, tidy, and free from clutter. Staff had received fire warden training, and fire safety equipment within service dates and stored safely.

One cubicle was used to store emergency equipment, oxygen cylinders, and a radioactive spill kit. Staff checked this equipment regularly and kept clear records of these checks. The automated external defibrillator (AED) was in working order and within its service date. Oxygen cylinders were stored safely and were within their expiry dates, in line with guidance. The service had recently completed a routine health and safety audit, which identified no areas of non-compliance.

Radiation safety was a key part of the service. Radiation monitoring equipment was available throughout the location and was used regularly to check for contamination while preparing or giving the radiotracer to patients. Staff and visitors also wore personal dosimeters, which are devices used to monitor radiation exposure. Readings were reviewed routinely to make sure exposure remained within safe limits.

Sharps and clinical waste that contained radioactive material were stored safely in suitable containers within the radiopharmacy. These items remained in storage until they were no longer radioactive. They were then disposed of using the nearby trust's procedures, in line with relevant requirements. The safe management of radiotracers is discussed further in the ‘Medicines optimisation’ section of this report.

The service had an appointed Radiation Protection Adviser (RPA) and Medical Physics Expert (MPE), in line with national guidance. The RPA carried out an annual radiation safety audit. We reviewed the actions from the most recent audits and found that all actions had been completed promptly before the next audit took place.

The service kept an up-to-date list of its equipment, including identification numbers and service due dates. Staff understood which equipment needed regular maintenance and checks. The service had clear arrangements for managing equipment, including items that were not currently in use. Staff were aware of these items and ensured they continued to be maintained where required.

The PET-CT scanner was serviced and calibrated regularly in line with requirements. The service had effective systems in place to bring in engineers quickly when occasional faults occurred with the scanner. The provider also operated a planned replacement programme for imaging equipment, including the PET-CT scanner.

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 clinical and support staff with the right skills, qualifications, and experience to provide safe care and meet patients' needs. The team consisted of 11 permanent staff members, of which 5 worked full-time and the remaining staff worked a range of part-time hours. The service did not routinely use agency or bank staff. When needed, staff from other locations within the provider could cover absences, provided they had the required training and skills.

Staff told us there were enough team members to meet demand safely and effectively. Although the service was busy at times, staff were able to take breaks during their shifts. Patients were seen promptly, and staff had enough time to provide compassionate care and answer questions or concerns.

The team included radiographers and radiography assistants. Administrative tasks were shared across the team, so dedicated administrative staff were not required on site. The service also had access to the on-call radiologist team at the referring specialist NHS trust and therefore did not need to employ its own medical staff.

The provider carried out professional registration checks and Disclosure and Barring Service (DBS) checks during recruitment and repeated these every two years. The provider also had systems to monitor staff fitness to practise and ongoing professional registration. If a staff member's registration lapsed, they would be removed from clinical duties until the issue had been resolved.

New staff completed a detailed local induction that was tailored to their role and completed within an agreed timeframe. We reviewed a completed and signed induction record. This included a checklist to confirm that new staff had read the policies and procedures they needed before working independently.

The service reviewed staff competence and training needs regularly. All staff completed an annual appraisal, also known as a personal development review (PDR), as well as a mid-year review. At the time of inspection, all staff were up to date with these reviews. Staff told us that working closely as a team meant knowledge, skills, and competence were checked and supported during day-to-day work.

The service provided mandatory training in key areas for all staff, as well as additional role-specific training, where needed. Managers had effective systems for monitoring training compliance and reminding staff when updates were due. Managers also reviewed changes in national guidance and patient safety alerts to identify any learning needs.

Staff were up to date with the mandatory training required by the provider. Overall compliance was 98%, and staff had already been booked onto training in the small number of cases where updates were overdue. However, we found that the service's learning disability and autism training did not meet statutory requirements. This is discussed further in the ‘Person centred care’ section of this report.

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.

The service managed infection risks well. Staff used equipment and followed procedures to protect people from infection. The location and equipment were visibly clean, and furniture and fittings were suitable for effective infection prevention and control. Handwashing sinks and alcohol hand gel were available throughout the location. The service also had effective procedures for dealing with body fluid spillages, including radioactive body fluids.

Infection prevention and control was included in the provider's mandatory training programme, and all staff were up to date with this training. During the inspection, we saw staff following bare below the elbows guidance, using personal protective equipment (PPE) correctly, and following infection control procedures during clinical care. Staff cleaned furniture and equipment after each patient.

The provider had policies and procedures for infection prevention and control, hand hygiene, environmental cleaning, and the management of infectious diseases. These were up to date and suitable for the service. The service carried out monthly infection prevention and control audits. The most recent audit showed full compliance. The service had also completed a more detailed annual audit, which found 97% compliance and showed consistently good performance. Any issues identified through audits were addressed promptly.

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.

The main medicine used by the service was the radiotracer fluorodeoxyglucose F 18. This is a small dose of radioactive fluid that is injected into a vein before a PET-CT scan. Because the radiotracer is radioactive, there are strict legal requirements for how it is transported, stored, used, and disposed of. The service had effective systems in place to maintain the licences required by the Administration of Radioactive Substances Advisory Committee (ARSAC). Staff followed a range of medicines policies and procedures and showed a good understanding of how to handle radioactive materials safely. This included specialist training in intravenous (IV) cannulation.

The provider had clear systems for manufacturing and quality testing the radiotracer, which staff understood and followed. Because the radiotracer has a short lifespan, a separate sample was tested by the manufacturer while the main supply was being transported to the service. Once testing confirmed that quality requirements had been met, the code needed to unlock the transport container was sent to the service.

The radiopharmacy contained a dose dispenser. The amount of radiotracer given to each patient was calculated using a standard protocol based on their height and weight. Staff understood the importance of administering the radiotracer within strict time limits. Calibration times and expiry times were clearly shown on each dose to reduce the risk of error.

Medicines and radiopharmaceuticals were discussed regularly at provider-level medicines quality meetings. These meetings reviewed incidents and identified trends across the provider's different locations. Medicines issues were also discussed at local service meetings so staff could receive updates and new guidance.

The service also kept a small number of medicines for use in emergencies, including adrenaline, glucogel, and salbutamol inhalers. These medicines were checked regularly and were all within their expiry dates.