InHealth Jarvis Breast Screening 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 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. At our last inspection we rated this key question good. At this inspection, the rating has remained good. This meant people were safe and protected from avoidable harm. Staff received appropriate training and attended appraisals, however, the provider did not evidence training updates in staff appraisal meetings, nor plans of how to improve training uptake. The service did not always make sure there were enough qualified, skilled and experienced staff who received effective support and development, with recruitment being a slow process where staff were reported to not be updated. There was a disconnect between staff and leaders where clear and open communication was not always offered.

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 this service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety and were transparent with people. 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 routes for people to raise concerns and people were aware of who they could speak to if they encountered any problems.

Staff listened to concerns about safety and managers investigated and reported safety events. Staff were aware of incidents and how to report them. Staff utilised an online tool to report incidents and the registered manager would complete the screening incident assessment forms (SIAF) requiring submission. In the last 12 months, 12 SIAFs had been completed. There had been 25 incidents reported at the breast screening centre in the last 12 months, ranging from no to low harm. Some of these incidents included reports of people receiving screening too close to a previous screening date, which meant they had been exposed to a higher amount of radiation than required, however, posters were located within the imaging sites to remind people to report if they have had imaging within the last 12 months and to show proof of this, staff also questioned the person about this prior to receiving the screening. For people who last had imaging over 12 months ago the service accepted the verbal dates people provided. It was documented within the incidents lists that there was nothing more the service could do to avoid this reoccurring issue, other than ensuring individuals were accurate regarding their previous screening dates. However, the service had also contacted another organisation to enquire whether they had any examples of good practice they could share to support improvements in this area.

Staff were transparent towards people and understood the need to provide explanations when things went wrong. We were provided with examples of when things had gone wrong such as a pathology error which led to a person receiving incorrect results. The team were transparent and provided reassurance to the person whilst the next steps were explained. There was evidence that changes were made as a result of feedback, for example people had complained that when giving their personal details in the mobile centres, others could hear them. Leaders reviewed the Standard Operating Procedure, and this was changed to enable people to give their personal details in the X-ray room and not the reception area.

We scored this 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. Staff made sure there was continuity of care, including when people moved between different services.

Staff planned and organised care and support with people, together with colleagues in ways that ensured continuity. Staff liaised with external partners to manage safe systems of care for people, such as a local pathology service. A nurse explained how information was sought from people to make sure they were best prepared for how to provide safe and effective care, this included being aware of people’s concerns.

The service had a high-risk appointments process, which was aimed at people who were deemed a higher screening risk. This could be due to multiple factors, such as secondary genetic conditions or family history. An annual invitation was sent to a select number to ensure their risk was reduced. We were told monthly, quarterly and annual audits were undertaken for high-risk people to monitor and mitigate risk.

Staff worked with the necessary healthcare professionals to ensure people had continuity of safe care, both within the service and to the onwards provider. The service consisted of a multidisciplinary team of professionals who worked with local NHS trusts to suit the needs of people.

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. Staff 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 received adult and children safeguarding training within the induction programme and then completed ongoing safeguarding within their mandatory training. Staff knew how to escalate safeguarding concerns. As of April 2025, for staff who were required to undertake Safeguarding Adults level 2 training 98% were up to date, 93% were trained to Safeguarding level 3 and 94% had completed the Safeguarding Children level 2 training. The evidence provided did not clearly demonstrate what the uptake was for Safeguarding Children level 3. Ninety-six per cent of staff received training for Mental Capacity and Deprivation of Liberty Safeguarding.

The service did not provide services to children, however, staff followed safe procedures for children visiting the service with an adult. An example of this was when a person who had brought their child with them was denied screening as their child was not able to be cared for whilst the adult received the screening. Adults were discouraged from bringing children to their screening appointments prior to the appointment as there were no suitable persons to care for children during the screening process.

There was no restraint or restrictive practice in use, however, staff were aware of what to do when prisoners attended the service, they were able to confidently explain the process to keep both people safe.

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 saw people received consistent support from staff to manage risks associated with their health and wellbeing. Staff provided care to meet people’s needs that were safe and supportive. This was shown through staff understanding of how to explain procedures to people clearly and with empathy. Staff were knowledgeable about risks, including where to take people in the case of a fire alarm sounding.

Staff communicated with people in ways that were effective for people, they knew of tools they could utilise to have clear conversations with people, such as easy read documents and translators.

Staff enabled people to give feedback on the service they received, the feedback box was located by the exit which meant it was easily visible to people.

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.

There were regular audits undertaken of the equipment to ensure the equipment was safe to use. Staff were able to explain when there would be fire alarm tests and where people should go in the event of a fire. We observed areas which were not used due to equipment awaiting repair, in the meantime the rooms were repurposed, such as one space being used for training.

The area local rules under the Ionising Radiations Regulations 2017 were available in each room, these were all in date and had radiation protection supervisor (RPS) information on the top of the front page, this meant if there were any radiation concerns staff could quickly find information on who to contact.

It was a controlled area with warning lights on the outside of the imaging rooms, these would illuminate when people were being imaged, which alerted people and reduced the risk of others entering the room whilst the imaging was taking place.

The equipment servicing had recently moved to a different maintenance contract under the same provider, which meant there were some changes to the service provision, however, the service still provided equipment repairs and replacements as required. The facilities and equipment met the needs of people, were clean and any risks were mitigated.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff told us there was no flexibility for leave or sickness and the staffing numbers were very tight for clinics. Staff also felt there was a risk of staff burnout as clinics were not reduced when staff left. However, leaders informed us that bank and agency staff were used to ensure clinics were appropriately staffed.

Some staff told us they did not always receive effective support and development. We received evidence of staff appraisals being undertaken. Staff told us that they could discuss future training and courses they wished to undertake within these meetings, however, this was not documented in the appraisals we reviewed. The provider supplied evidence which showed training compliance was discussed at appraisals. The service provided mandatory training in key skills to staff, however, not all staff remained up to date with the courses. The training staff received was relevant to ensure people were protected and kept safe such as basic life support, however, the completion rate for this training from April 2025 was at 65%. However, staff worked well together to provide safe care that met people’s individual needs. There had been a high turnover of staff causing the service to utilise agency staff. From May to December 2024, 11 staff members left the service. It was documented that staff left for reasons such as career changes and planned agreed exits, however, staff told us lots of staff left due to how they believed other staff had been treated by leaders. The 2024 staff survey results showed the lowest scored themes were with regards to leadership and recognition.

Staff told us they were short staffed and were not kept informed of recruitment. However, the meeting minutes showed workforce changes including staffing and recruitment plans were discussed. The evidence did not demonstrate if all staff were informed of the information or how it was disseminated to those outside of the meeting.

The risk register identified the highest operational risk as delays in people receiving results and delays to key performance indicators (KPIs), caused by staffing shortages in pathology services provided by a different healthcare provider. There had been difficulties recruiting within the service, with two positions open for over 340 days, however, control measures were in place. Two other positions which had been recruited for had been filled. Agency and bank staff were used to fill vacancies. Staff concerns matched those that were on the risk register.

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.

All clinical areas appeared clean and tidy. Staff adhered to infection control principles, including handwashing and being bare below the elbow. There was personal protective equipment readily available in rooms. Hand hygiene audits were to be completed every 3 months. The audits we reviewed showed staff adhered to appropriate hand washing techniques, however, they were not always completed within the 3 month timeframe. The provider showed us a site-specific cleaning sheet which detailed where the cleaning team were required, this demonstrated that the team had oversight of the cleaning requirements. There was a recent cleaning audit completed in January 2025 which attained a 96% audit score.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.